Health inspection·November 8, 2023

F 0552 facility went over risks and side effects regarding the medication melatonin for Resident #2. Level of Harm - Minimal harm or potential for actual harm Resident #7 Residents Affected - Some Record review of Resident #7's admission record, dated 10/24/23, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), insomnia (sleep disorder), and muscle weakness. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 05 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #7 dated 07/27/23 revealed a focus area I take melatonin for insomnia and interventions to give med as ordered notify MD if not effective for sleep, dated 09/28/23. Record review of Resident #7's order summary report dated 11/06/23 revealed the following orders: Melatonin oral tablet 5 mg (melatonin) Give 1 tablet by mouth at bedtime related to Insomnia, unspecified, dated 08/17/23. Record review of Resident #7's medication administration records undated for the month of November 2023 revealed resident received Melatonin 5mg at 08:00 PM on 11/1/23, 11/2/23, 11/3/23, 11/4/23, 11/5/23, and 11/6/23. Record review of Resident #7's electronic medical record scanned documents on 11/07/23 revealed no consent for melatonin. The surveyor attempted to interview Resident #7 on 11/08/23 at 8:40 AM but she was asleep. Resident #22 Record review of Resident #22's admission record, dated 11/06/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease, unspecified (breathing disorder), Insomnia, unspecified (sleep disorder) and anxiety disorder unspecified (psychological disorder). Record review of the quarterly MDS assessment for Resident #22, dated 8/24/23 revealed that the resident had a BIMS score of 12 indicating that he was cognitively intact. Record review of the care plan for Resident #22 dated 11/6/23 revealed the following Focus, I have insomnia. Medication: melatonin. Interventions included, Assess for cause of insomnia and document in clinical record. Date initiated: 8/1/23. Record review of Resident #22's order summary report dated 11/06/23 revealed the following orders: Melatonin oral tablet 5 mg (melatonin) Give two tablets by mouth at bedtime related to insomnia, dated 07/12/23. Record review of the clinical records for Resident #22 regarding medications revealed that the resident had no documentation of a consent for melatonin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 2 of 45 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 11/08/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 11/08/23 at 8:42 AM, Resident #22 stated he knew about the medication melatonin but did not remember the facility staff going over risks and benefits for the medication. Resident #25 Record review of Resident #25's admission record, dated 11/06/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include sepsis (the body's extreme response to infection), type 2 diabetes mellitus (high blood sugar), and insomnia (difficulty sleeping). Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #25 was understood. The MDS revealed Resident #25 had a BIMS score of 15 which indicated the resident's cognition was intact. Record review of a care plan dated 08/18/23 for Resident #25 revealed a Focus - I have insomnia Medication: melatonin; Goal - I will sleep 6-8 hours per night through the review period; Interventions Administer medications as ordered by MD. Record review of Resident #25's order summary report dated 11/06/23 revealed the following orders: Melatonin Oral Tablet 5mg Give 2 tablets by mouth at bedtime related to insomnia, dated 06/09/23. Record review of Resident #25's electronic medical record revealed no consent for melatonin. Interview on 11/08/23 at 9:25 AM, Resident #25 stated she was aware that she was taking the medication melatonin but did not remember the facility going over risks and side effects of the medication. Resident #25 stated she did not remember giving consent for melatonin to be added to her medications. Resident #33 Record review of Resident #33's admission record, dated 11/06/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include major depressive disorder (psychological disorder), anxiety disorder (psychological disorder), insomnia (sleep disorder), and Alzheimer's disease with early onset (cognitive disorder). Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #33 had a BIMS score of 2 indicating that the resident was cognitively impaired. Record review of the current care plan for Resident #33 dated 8/23/23 revealed a Focus, I have insomnia. Medication's: temazepam, melatonin. Interventions, Assess for cause of insomnia and document in the clinical record. Date initiated: 8/23/22. Record review of Resident #33's order summary report revealed the following order: Melatonin oral tablet 5 mg (melatonin) Give two tablets by mouth at bedtime for insomnia, dated 6/20/23. Record review of the clinical record for a Resident on #33 revealed that he had no documentation of a consent for the use of melatonin which was ordered for insomnia. Resident #37 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 3 of 45 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 11/08/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #37's admission record, dated 11/07/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia (blood sugar disorder), anxiety disorder (psychological disorder), dependence on renal dialysis (kidney dysfunction), and end-stage renal disease (kidney failure). Record review of the admission MDS assessment dated [DATE] revealed that Resident #37 had a BIMS score of 14 indicating she was cognitively intact. Record review of the current care plan for Resident #37 dated 10/29/23 revealed a Focus - DX: CHF. Ms. (Resident #37) has congestive heart failure. Interventions - monitor/document sleeping pattern. Inform physician of any insomnia or anxiety. Give sedatives as ordered. Record review of Resident #37's order summary report revealed an order: Melatonin oral tablet 3 mg (melatonin) Give one tablet by mouth every 24 hours as needed for insomnia, dated 10/23/23. Record review of the clinical records for Resident #37 revealed that she had no documentation of a consent for melatonin. Resident 57 Record review of Resident #57's face sheet, dated 11/06/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus (high blood sugar), pain in unspecified joint, and muscle weakness. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #57 was understood. The MDS revealed Resident #57 had a BIMS score of 08 which indicated the resident's cognition was moderately impaired. Record review of a care plan dated 08/29/23, for Resident #57 revealed a Focus - I have insomnia Medications: Melatonin; Goal - I will sleep 6-8 hours per night through review period; Interventions Administer medications as ordered by MD. Record review of Resident #57's order summary report dated 11/06/23 revealed the following order: Melatonin Oral Tablet 5mg Give 1 tablet by mouth every 24 hours as needed for insomnia, dated 02/16/23. Record review of Resident #57's electronic medical record revealed no consent for melatonin. Interview on 11/08/23 at 9:30 AM, Resident #57 stated he was not aware of the order for medication melatonin. Resident #57 stated he was not informed of the risks and side effects regarding the medication melatonin. Interview on 11/08/23 at 10:05 AM, the ADON and DON stated they were both responsible for obtaining psychotropic medication consents. The ADON and DON stated the melatonin consents were not obtained due to training from corporate to follow a list of psychotropic medications requiring consent, dated 01/23. The ADON and DON observed Texas Health and Human Services Form 8763, dated 05/23, and confirmed melatonin was on the list of psychotropic medications requiring a consent. The DON stated the potential negative outcome to the residents was they may not be aware of the side-effects of the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 4 of 45 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 11/08/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Interview on 11/08/23 at 10:13 AM, the ADM stated the nursing administration staff (DON and ADON) were both responsible for ensuring psychotropic consents were in place. The ADM stated the consents were missed because the facility missed the memo about the psychotropic medication list being updated to include melatonin. The ADM stated the potential negative outcome to the residents was resident right concerns and the resident could have an allergic reaction to the medication. Residents Affected - Some Record review of facility policy titled, Psychotropic Medication Use, dated 07/22, reflected the following: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .d. Hypnotics 3. Residents, families, and/or the representative are involved in the medication management process. Resident Evaluations: .4. Residents (and/or representatives) have a right to decline treatment with psychotropic medications. a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. Record review of the facility's policy titled, Drug Therapy, dated 01/01, reflected the following: Policy Statement: Each resident's drug regimen shall be free from unnecessary drugs. Policy Interpretation and Implementation: .2. A comprehensive assessment of the resident's drug therapy will include: .e. consent for psychoactive drugs Record review of the Texas Health and Human Services Form 8763 titled, Informed Consent or Authorization for Administration of Psychotropic Medication, dated 05/23, reflected that melatonin was on the list of psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 5 of 45 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 11/08/2023 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 interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 15 residents (Resident #54) reviewed for PASRR screening, in that: Residents Affected - Few Resident #54 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. This failure could place residents with an inaccurate PASRR Level 1 Evaluation and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings included: Record review of Resident #54's electronic face sheet dated 11/07/2023 revealed a [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Major Depressive Disorder. Record review of Resident #54's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Major Depressive Disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 10 indicating the resident was moderately, cognitively impaired. Record review of Resident #54's most recent care plan, undated, revealed a focus area and diagnosis of Major Depressive Disorder, this problem started 12/22/2022. Resident #54 was prescribed Cymbalta 30mg once a day and Risperdal 4mg once a day to assist with this area of need. Record review of Physician progress notes for Resident #54 dated 11/07/2023 revealed under current medications, Resident #54 was prescribed Cymbalta 30mg once a day for depression and Hydroxyzine 25mg once a day to assist with anxiety. Record review of Resident #54's Preadmission Screening and Resident Review Level One (PL1) form dated 12/08/2022 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. During an interview conducted on 11/08/23 at 11:08am with the ADM, he verified Resident #54 had a diagnosis of mental illness, Major Depressive Disorder. The ADM verified Resident #54 did not have a PASRR 2 Evaluation as her PASRR 1 Evaluation was negative. The ADM stated it was the MDS nurse's responsibility to ensure the PASRR 1 Evaluation was accurate. The ADM stated the purpose of the PASRR 1 Evaluation was to identify if a Resident required additional services. He said if the PASRR 1 Evaluation was positive then the MDS Coordinator contacts the Local Mental Health Authority to request the completion of PASRR 2 Evaluation. The ADM stated Resident #54's PASRR 1 Evaluation should be positive due to her diagnosis of Major Depressive Disorder. He said the MDS nurse was responsible for entering the PASRR 1 Evaluation into the system. The ADM stated the potential harm if a resident with a diagnosis of a mental illness who had a negative PASRR 1 Evaluation, and no subsequent level two evaluation was the residents could potentially go without services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 6 of 45 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 11/08/2023 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 - Few During an interview with the MDS nurse on 11/08/23 at 10:40am, she stated Resident #54 did not have a PASRR 2 Evaluation as Resident #54 had a negative PASRR 1 Evaluation. The MDS nurse stated Resident #54's PASRR Level 1 was not accurate due to the Residents diagnosis of Major Depressive Disorder. The MDS Nurse stated it was her responsibility to ensure PASRR Level 1 Evaluations were accurate. The MDS nurse stated it was her responsibility to ensure every resident entering the facility had a completed and accurate PASRR 1 Evaluation. The MDS nurse stated she did not know why Resident #54 did not have positive PASRR 1 Evaluations due to having had a mental illness diagnosis. The MDS nurse stated the potential negative outcome for residents not having an accurate PASRR 1 Evaluation and subsequent PASRR 2 Evaluations would be the residents may not be offered the services they may need for their diagnosis. Record Review of the Preadmission Screening and Resident Review (PASRR) Policy Revised 1/16/2019 read: The facility policy for PASARR states all applicants being admitted to a Medicaid-certified nursing facility must have a Level 1 PASRR completed to screen for possible mental illness. Residents with positive PASRR Level 1 cannot be admitted to a Medicaid-certified nursing facility unless approved through Level 2 PASRR determination. Those Residents covered by Level 2 PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. Specialized Care Plans should be developed and followed for Residents with positive Level 2 PASRR Evaluations; the Local Mental Health Authority should be included in the development of the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 7 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 9 of 26 resident rooms (119, 120, 132/133, 134/135, 138, 139/140) located on 2 of 2 nurse stations (Station 1 and 2) and 1 of 1 beauty shop and reviewed. The facility further failed to accurately assess each resident's status for safe smoking for one of one resident (Resident #49) reviewed for smoking assessment. The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 117.9 to 124.2 F at 9 of 26 resident room hand sinks located on Stations 1 and 2 and beauty shop shampoo basin. The facility failed to ensure used needles were transported in a safe manner in resident use areas at 1 if nurse stations (Station 2), and The facility failed to complete a safe smoking assessment for Resident #49 upon admission and monthly. These failures could place residents at risk for injuries and infections related to skin punctures and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water. These failures could also put residents who smoke at risk of not receiving the proper care and supervision while smoking. The findings include: -Water Temperatures: Observation on 11/6/23 at 10:34 AM revealed room [ROOM NUMBER]'s hand sink hot water temperature was 117.9°F . This was witnessed Hospice RN A. Observation on 11/6/23 at 10:49 AM revealed hand sink room [ROOM NUMBER]'s hot water was 118.4°F. Observation on 11/6/23 at 12:16 PM, revealed the restroom that was shared by rooms [ROOM NUMBERS] had water temperature at the hand sink of 124.2°F and rising. Observation on 11/6/23 at 12:19 PM revealed the restroom shared by 132 and 133 had hot water at 120.2°F and rising at the hand sink. Observation on 11/6/23 at 12:20 PM revealed room [ROOM NUMBER]'s hand sink had hot water was 122°F and rising. Observation on 11/6/23 at 12:21 PM revealed the restroom hand sink shared by rooms [ROOM NUMBERS] was 120.2°F and rising. The Social Worker witnessed the water temperatures in the restrooms of rooms 132/133, 134/135, 138, and 139/140. During an interview on 11/16/23 at 12:44 PM, the Administrator stated that facility had purchased a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 8 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm new water heater . He stated that facility staff had been adjusting the water heater off and on and temperature problems were occurring more on the east side of the building. Observation on 11/6/23 at 1:05 PM revealed the hot water at the beauty shop shampoo basin was 116°F. Residents Affected - Some On 11/6/23 at 11:18 AM an interview and observations were conducted with Maintenance Supervisor He stated he was hired mid-January (2023) around the 15th or 16th. He stated that the facility had purchased a new water heater approximately five months ago. He added, he had a problem with regulating the water temperatures. He stated the southwest portion of Station 2 would be approximately 100 degrees F but then if he turned up the water heater, then the far (northeast) portion of Station 2 would get high temperatures. He said, he had called plumbers numerous times, and they just adjust the temperature. The plumbers recommended some water heater units get replaced. One plumber said one water heater was [AGE] years old and could not be repaired anymore. He stated he told the plumber he would give the recommendations to the Administrator. Regarding his water temperature procedures, he stated, he tested 4 or 5 rooms on each side of the halls. Temperatures were taken for about two or three minutes. When the thermometer stops rising, he would record the temperature. He added the water testing schedule would come up in the TELS online maintenance scheduling and documentation system one time a week. He stated that he would pick a day each week to conduct water testing. He added that he usually conducts the testing after lunch. Observations of the water heater located near room [ROOM NUMBER] (Station 1 - northwest) revealed that the temperature adjustment was set slightly below the letter B (approximately 140 degrees F) on the water heater. At that time the Maintenance Supervisor stated the water heater was connected to a pump to re-circulate the water. At the time the temperature dial was at 125°F. Observation of the water heater for the north central front shower area was made. The Maintenance Supervisor stated the water heater was replaced in 2013. He added It's old and needs to be replaced; pretty soon it will be out. He stated the new hot water heater was on Station 2 on the far end of the hall (northeast) near room [ROOM NUMBER]. On 11/6/23 at 1:25 PM observations and interviews were conducted with the Maintenance Supervisor. Observation of the new water heater near room [ROOM NUMBER] revealed it was set on the letter A area (approximately 130 degrees F). The Maintenance Supervisor stated the letter A setting was the lowest setting. He added the water heater instructions state to start at the arrow area (approximately 120 degrees F) and that the A setting was higher than the arrow. Regarding water heaters controlled which areas of the facility, he stated, he was trying to figure all that out. Regarding which water heater controlled the beauty shop he stated, he thought the (boiler room) gray water heater controlled the beauty shop and the bath at Station 2. He added the white (boiler room) water heater controlled the laundry. The gray water heater was observed set a little above the letter A on the adjustment dial. Observation on 11/6/23 at 1:36 PM revealed the center hall water heater had the temperature dial reading 99.5°F. Observation on 11/6/23 at 1:37 PM revealed the boiler room gray water heater temperature dial was reading 110°F. The white water heater was reading a temperature of 122°F. Observation on 11/6/23 at 1:38 PM revealed the water heater near room [ROOM NUMBER] (Station 2 northeast) had the temperature dial reading 105°F. On 11/6/23 at 1:45 PM the Maintenance Supervisor stated, the facility had a gas check in October, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 9 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some and he had to go back and readjust everything including the water heaters. He stated the Maintenance Supervisor was responsible for ensuring that water temperatures were maintained in a safe range. He then stated that he checked the temperatures around 2:30PM or 3:00 PM. He added that the plumber only mentioned to replace the water heater that they had replaced near room [ROOM NUMBER]. He added that water heater was replaced 4 to 5 months ago. He also stated he had worked as a plumber previously for 8 years. He stated residents could scald or burn themselves as a result from water temperature not being maintained in a safe range. During an interview on 11/6/23 at 2:25 PM, the Maintenance Supervisor stated, regarding the hot water heater near room [ROOM NUMBER] (Station 1 - northwest), that the dial temperature was 130°F. On 11/6/23 at 2:51 PM an interview was conducted with the Administrator. He stated the reports for water temperatures, in the TELS system, would not let the Maintenance Supervisor document multiple temperatures taken. Observation on 11/6/23 at 3:16 PM revealed the hot water in room [ROOM NUMBER] was 119°F. On 11/7/23 at 8:25 AM an interview was conducted with the Maintenance Supervisor. He stated, the TELS system would only let him document one water temperature entry on his phone. He added that this was the first place he had used online maintenance documentation and scheduling system. On 11/7/23 at 9:30 AM an interview was conducted with the Maintenance Supervisor regarding the hot water issues in the facility. He stated, he had adjusted the water heaters about 7:15 AM to 7:20 AM (11/07/23) and would check the temperatures again at about 11 AM (11/07/23). He added the last three rooms read high that were near room [ROOM NUMBER] and was trying to figure out which water heater controlled what portion of the halls. He stated the whole time he had been in the facility; he had been trying to figure out the water heaters. He added, no one had told him which water heaters controlled which areas. He stated he had not received an orientation to the building and no regional assistance related to orientation and training in maintenance. He added that one time, approximately 6 months ago, there was a corporate Life Safety Code person who walked through the building and told him things he might work on. He stated that he shoots for maintaining hot water no higher than 110°F and no lower than 100°F. Regarding why he was unable to maintain the water temperatures in a safe range, he stated, he just barely knew about the hot water heater instruction book. - Needle Safety Observation and interview on 11/7/23 at 8:56 AM revealed LVN A walked from room [ROOM NUMBER] to the nurses medication treatment cart, which was approximately 20 feet and had an expose needle from an insulin pen in her hand, holding it with the needle pointing up. She stated, she administered Resident #22 10 units of Humalog R, referring to the resident in room [ROOM NUMBER]. She further stated the insulin pen needles were not retractable, so would hold them upward until she got to a sharps container. She added that the insulin pen she had just used did not retract like others. On 11/7/23 at 10:26 AM an interview was conducted with LVN A . She stated she found a better way to transport the needle. She stated she could use the lid, but not twist it down to recap it. She added she thought the insulin pens that push up to the stomach and retract were better. She stated she was taught in nursing school not to recap needles and that was why she did not recap. She added that now she would cover the needle and not twist down when transporting an exposed needle. She stated, she did not recap; that was why she had held the needle up when walking down the hall. She stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 10 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some herself and the medication aide were responsible to ensuring that needles were transported in a safe manner. She stated, she would now cover the needle until she got to the medication cart. She stated, there were tests on the online in-service system, but no specific training for needle safety. She stated, if she bumped into someone and caused her to fall, she could accidentally poke someone. On 11/8/23 at 11:07 AM an interview was conducted with the DON regarding issues observed. She stated that carrying an exposed needle in a public corridor was not part of the facility process or procedure. She added the medication cart should have been at the door of the resident. She did not take the cart to the room and there was not an excuse. She stated the nurse was responsible for ensuring the safe transporting of needles. She stated audits were conducted periodically. She stated, she had not conducted any in-service related to needle safety this year. She added that the topic was part of the online in-service training system staff use. She stated there could be an accident and stick someone. Staff could inject insulin in a person and get infected with a dirty needle. -Smoking Safety Record review of Resident #48 face sheet, dated 11/06/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes (high blood sugar), respiratory failure, kidney failure, muscle weakness, and unsteadiness on feet. Record review of Resident #48's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #48 had a BIMS score of 15 which indicated Resident #48's cognition was intact. Section J1300 revealed Resident currently used tobacco. Record review of Resident #48's care plan, dated 07/20/23, revealed Resident was a smoker and a burn risk. Care plan further revealed the intervention to provide smoking apron and gloves to resident to go outside to smoke. Record review Resident #48's electronic medical record under the assessment tab on 11/08/23 revealed no smoking assessment completed. During an interview on 11/08/23 at 09:05 AM with Resident #48, she stated she has smoked for years. She stated she does not go out at the nursing home and smoke a lot. She stated her cigarettes were kept in her bottom dresser drawer. During an interview on 11/08/23 at 11:30 AM with the DON, she stated Resident 48 did not have a completed smoking assessment in her electronic medical record. She stated nursing was responsible for completing smoking assessments. She stated a smoking assessment was to be done with the resident that smokes. She stated when Resident #48 was admitted she did not smoke. She stated when she came back from a hospital stay, she wanted to go outside and smoke. She stated Resident #48 had only smoked two cigarettes since she returned from the hospital. She stated residents were allowed to have cigarettes in their rooms if they were safe and if they were not safe, they were kept at the nurse's station. She stated residents were determined safe or not safe by their smoking assessments and just by knowing the resident. She stated the potential negative outcome of not doing a smoking assessment could lead to a resident getting burned. She stated all nursing staff were trained to complete a smoking assessment on all residents who smoke. On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated Staff did not monitor water temperatures close enough and the hot water was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 11 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm not being regulated. He further stated corporate life safety code staff visit quarterly. Regarding what he expected staff to have done, he stated, staff needed to let the Maintenance Supervisor know if things were not working, and then get assistance from a plumber. He stated the Maintenance Supervisor was responsible for ensuring that the hot water was within safe ranges. He stated, residents could get burned; it could harm a resident. Residents Affected - Some On 11/13/23 at 4:15 PM an interview was conducted with the Administrator regarding staff walking in public corridors with exposed needles . He stated staff did not have her cart with her. He stated staff should have followed the policy and if the needle was not capable, she should have had a sharps container with her. He stated, staff could have stuck someone or stuck themselves. During an interview on 11/10/23 at 11:45 AM with the ADM, he stated nursing administration was responsible for completing smoking assessments. He stated the smoking assessment should be completed as soon as you know the resident smokes or on admission. He stated Resident #48 occasionally wants to smoke and should have has a smoking assessment done to make sure she was safe. He stated the potential negative outcome could be resident catch on fire and harm to the resident. Review of the current undated American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. Record review of the facility plumbing vendor invoice dated 4/6/23 revealed the following documentation, Plumbing. Will pull permit with the City for 75-gallon gas water heater permit for the northeast mechanical room Install a new water heater and pan. Record review of the facility's, Logbook Documentation in the TELS online maintenance scheduling and documentation system for water temperatures revealed that temperatures were taken in the facility approximately weekly. Record review of this documentation from 8/2/23 through 11/2/23 revealed that each week's documentation only documented one temperature each week. Further record review of all 14 weeks of documentation revealed that the temperatures range from 103.8 to 106.5°F. It was documented that the locations where temperatures were taken were not specific. Eight of the 14 documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 12 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some temperatures were only labeled (Facility) building. Five of 14 were labeled Station 1 & 2. 1 of 14 was labeled with a group of room numbers but only one temperature was documented of 105.6°F Fahrenheit. The rooms listed were 122, 113, 104, 132, 144 and 140. Each of the 14 documented weekly temperature logs only documented one temperature for an area. Record review of the Use and Care Manual with Installation Instructions for The Installer for The Gas Water Heater revealed the following documentation, The purpose of this manual is twofold: 1., to provide the installer with the basic instructions and recommendations for the proper installation and adjustment of the water heater; and 2., for the owner operator, to explain the features, operation, safety, precautions, maintenance and troubleshooting of the water heater. This manual also includes a parts list. It is imperative that all persons who are expected to install, operate, or adjust this water heater, read the instructions carefully, so that they may understand how the pro to perform these operations. If you do not understand these instructions, or any terms within it, seek professional advice. Important safety information read all instructions before using. Danger exclamation point water temperature setting. Safety and energy conservation are factors to consider when selecting the water temperature setting of a water heaters gas control. Water temperature above 125°F parentheses 52°C parentheses close can cause severe burns or death from scalding. Be sure to read and follow the warning outlined on the label pictured below. The label is also located on the water heater. Time/temperature relationship and scalds. Water temperature 120°F. Time to produce a serious burn more than five minutes. Water temperature 125°F . Time to produce a serious burn - 1.5 to 2 minutes. The chart shown above may be used as a guide in determining the proper water temperature for your home.! Danger: household with small children, disabled, or elderly persons may require a 120°F (49°C) or lower gas control (thermostat) setting to prevent contact with hot Water.! Danger: hotter. Water increases the potential for hot water scalds. Operating the water heater. Water temperature setting. Maximum water temperature is the current just after the burner has shut off. To determine the water temperature, turn on a hot water faucet and place a thermometer in the water stream. The reference mark (triangle/arrow shaped icon) on the rim of the temperature dial, represents an approximate water temperature of 120°F. The reference mark (letter A in a circle) represents an approximate water temperature of 130°F. Each reference mark above or below these points indicate an approximate change of 10°F. To adjust the temperature, turn the temperature down to an initial setting of 120°F. Further record review of the Use and Care Manual for The Gas Water Heater revealed a diagram that indicated the level B was approximately 140 degrees Fahrenheit setting. Record review of the facility policy, titled Water, Temperatures, Safety of, revised December 2009, revealed the following documentation, Policy Statement. Tap water in the facility shall be kept within a temperature range to prevent scolding of residence. Policy Interpretation and Implementation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 13 of 45 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 11/08/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some 1. Water heaters that service, resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than____ F (____C), or the maximum allowable temperature per state regulations. 2. Maintenance staff is responsible for checking, thermostats and temperature controls in the facility and recording these checks and a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., Hot enough to be painful or cause reddening of the skin after removal of the hand from the water) staff will report this finding to the immediate supervisor. 5. Direct care staff shall be informed of risk factors for scalding/burns that are more common in the elderly, such as: a. Decreased skin thickness; b. Decreased skin sensitivity; c. Peripheral neuropathy; d. Reduced reaction time; e. Decreased cognition; f. Decreased mobility; and g. Decreased communication. Record review of the facility policy, titled Maintenance Service, revised December 2009, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy interpretation, and implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building in good repair and free from hazards. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 14 of 45 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 11/08/2023 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 manner. Level of Harm - Minimal harm or potential for actual harm 10. Maintenance personnel shall follow Established safety regulations to ensure the safety and well-being of all concerned . Residents Affected - Some Record review of the facility policy, titled Needle Handling and/or Disposal, revised January 2012, revealed the following documentation, Purpose. To guide the safe handling and disposal of used needles. Objectives. To prevent needlestick injuries and exposure to the HIV (AIDS) and hepatitis B (HBV) viruses or other blood-borne infections through contact with blood or tissues. Safety Precautions. 1. After using a needle, if the needle disposal box is directly available, discard the needle without recapping. Record review of the facility policy, titled Standard Precautions, revised October 2018, revealed the following documentation, Policy Statement. Standard precautions are used in the care of all residents, regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions, presume that all blood, body, fluids, secretions, and excretion (except sweat) nonintact skin, and mucous membranes may contain transmissible infectious agents. Policy Interpretation, and Implementation . 2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision making in various clinical situations. Standard precautions include the following practices. 8. Safe Needle Handling. c. Use disposable syringes and needles, scalpel blades, and other sharp items are placed in appropriate puncture resistant containers located as close as possible to the area in which the items were used. Record review of the provided facility's policy titled Smoking Policy - Residents, revised 7/2017 revealed the following: Policy statement: This facility shall establish and maintain safe resident smoking practices . 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation) . 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 15 of 45 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (Resident #21). 1)The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a sanitary manner and followed physician orders for Resident #21. These failures could result in the spread of resident infections. The findings include: Record review of the Order Summary Report dated 11/6/23 for male Resident #21 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of dysphagia oropharyngeal phase (swallowing disorder), gastrostomy status (nutrition delivered through abdominal wall), contracture, unspecified, joint (reduced joint flexibility), personal history of traumatic brain injury (brain injury), anoxic brain damage, not elsewhere, classified (loss of oxygen to the brain), gastrostomy, complication, unspecified (difficulty with nutrition delivered through abdominal wall), moderate protein calorie malnutrition (malnutrition), and quadriplegia, unspecified (paralysis of all 4 limbs). Further record review of the Order Summary Report revealed the following orders: Peg tube residual check every shift, if over 100 ml hold feeding and notify physician every shift related to gastrostomy complication, unspecified. Order status active. Order date 6/9/23. Start date 6/9/23. Clean area around peg to with NS, pat dry, cover with split 4 x 4 gauze, one time a day related to quadriplegia, unspecified; gastrostomy complication, unspecified. Clean area around peg tube with NS pat dry, apply Calazinc and cover with split 4 x 4 gauze. Order status active. Order date 6/12/23. Start date 6/13/23. Tube feeding: H2O 51 ML/HR X 20 hours total water 1020 ML, two times a day for enteral feeding off at 8 AM and resume at 12 PM. Order status active. Order date 4/19/23. Start date 4/19/23. Tube feeding: Isosource 1.5 at 70 ML/HR X 20 hours with/H2O flush of 51ML/HR X 20 hours to provide 1400 ML formula volume 2100 kcals, 95 g proteins and 2090 ML H20 pump on at 12 PM and off at 8 AM two times a day for enteral feeding off at 8 AM and resume at 12 PM. Period. Order status active. Order date 4/19/23. Start date 4/20/23 Record review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed that the resident had no BIMS score and was documented as severely impaired cognitively - never/rarely made decisions. Further record review of this MDS documented the resident had Active Diagnoses that included quadriplegia, malnutrition, and aphasia (difficulty speaking). Additional diagnoses included gastrostomy complication, unspecified, indicated by ICD code K94.20. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 16 of 45 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the current care plan dated 8/02/23 for Resident #21 revealed the following Focus. (Resident #21) requires tube feeding R/T malnutrition dysphasia, weight expected to fluctuate R/T TF and dependent edema secondary to quadriplegia. Isosource 1.5 at 70 ML/HR HR X 20 hours. Flush with 30 ML before and after meds. Change syringe every night. Check residual every shift, hold, if 100 or above for one hour. Peg site care daily. Water flush 51ML/HR X 20 hours continuous. Pump at 12 PM and off at 8 AM. May use Coca-Cola to unclog G-tube2 PRN. Folic acid. Date initiated: 9/15/16. Revision on: 8/2/23. The Goal included, He will remain free of side effects or complications related to tube feeding through review date. Date initiated: 9/15/16. Revision on: 4/24/23. Target date: 1/21/24. Interventions/Tasks included, Checked for tube placement and gastric contents/residual, violent volume per facility protocol and record. Hold feed times one hour, if greater than 100 cc aspirate. Date initiated: 9/15/16. Revision on: 9/15/16. He needs total assistance with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 9/15/16. Revision on: 9/15/16. Provide local care to G-tube site as ordered and monitor for S/SX of infection and/or skin breakdown. Report site problems to MD. Date initiated: 9/15/16. Revision on: 12/29/16. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 9/15/16. On 11/6/23 at 10:43 AM Resident #21 was observed. The resident was on an air bed and was leaning to the left side in bed. The resident's hands were contracted and had random arm movements. A tube feeding pump was present with formula and water flush hanging. The tube feeding pump was off and the formula tubing was disconnected from the resident. The G-tube feeding formula tubing was looped over the pump pole and the end was uncovered/uncapped. The feeding formula was Isosource 1.5 CAL and the documentation on the bag was 11/5/23, 2100 70 ml/hr. The feeding formula level was approximately 450 mL. The water bag level was approximately 600 ml and was labeled, 11/3/23 1530 70 ML/HR. On 11/6/23 at 2:08 PM Resident #21 was observed in his room sleep on his air bed. The G-tube was on and connected. The water bag level was approximately at 575 ml and the Isosource feed level was approximately at 300 mL. There was a used flushing syringe present that was labeled 11/5/23 and had the initials for LVN D. The flushing syringe plunger was stored inside the barrel. The display on the Feeding pump was Feed rate 70 ml/hr, 2510 Flush, 8027 Feed, Flush 50 mL Every one hour. On 11/6/23 at 5:34 PM Resident #21 was observed in bed in his room. The G-tube was on, and the display read as follows: Feed rate 70 mL/hr, 2710 flush, 8255 Fed, Flush 50 ml Every one hour. The water bag level was approximately at 400 ml. The Isosource level was approximately at 100 ml. The used flushing syringe was stored in a bag with the plunger inside the barrel and the bag was dated 11/5/23 with the initials for LVN D. On 11/7/23 at 8:48 a.m. Resident #21 was observed in bed on an air bed. The G-tube pump was off. The flushing syringe was stored in a bag and the plunger was inside the barrel. The interior of the flushing syringe was wet. The level of the feeding Isosource was approximately at 475 ml and the water was approximately 900 at ml. The Isosource bag was labeled 70 mL/hour 11/6/23, 2145 and the water bag was labeled 11/6/23, 2145 H2O. Both bags were initialed by LVN B. On 11/7/23 at 10:26 AM an interview was conducted with Station 2 LVN A. She stated Resident #21 was reconnected to the G-tube at noon and disconnected at 8:00 AM. She added that his formula rate was 70 ml/hr and the water flush was 50 ml/hr. On 11/7/23 at 11:58 AM an observation was made of, and interview conducted with LVN A of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 17 of 45 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #21 being reconnected back to the G-tube pump feeding. At this time, she stated the feed was 70 ml an hour and the water flush was 51 ml an hour. This was what she was reading from the MAR documentation on her computer screen. Upon entering the room, the resident was in bed and had cracked dry and peeling skin on his lips. LVN A then brought in 2 cups of water, clean dressings and gloves on a tray and placed it on the overbed tray table. She also had a new flushing syringe. She washed her hands and donned pair of gloves. She checked for placement and bowel sounds. She checked for residual, and there was no residual. She flushed with 15 mL of water. She turned on the pump and the screen displayed the following: 70 mL/hr Feed, 3212 Flush, 8961 Fed, 50 mL flush every one hour. The level of the feeding Isosource was still approximately at 475 ml and the water flush was still approximately at 900 ml. The resident was reconnected to the g-tube and the flush amount remained at 50 ml every one hour and was not changed to 51 ml as ordered. LVN A removed the soiled dressing from the G-tube site and removed her soiled gloves and placed them on the same tray where there was a clean dressing to be placed on the G-tube site of the resident. She cleaned the site and placed clean dressings back on the G-tube site. Regarding why she had placed the soiled gloves and dressings on the tray with the clean dressing, she stated, she was trying to get the dressing on the resident's G-tube site. She further stated that normally she did not place the soiled dressings and gloves on the same tray with the clean items. She stated this was not the ideal way of performing the procedure by placing clean and soiled items on the same tray. She added she did place the soiled dressings and gloves near the dirty cups. Prior to leaving Resident #21's room, the LVN tossed all the soiled gloves and dressings and trash loosely and unbagged in the room trashcan that was on the A bed side. This resulted in a soiled glove from the treatment hanging on the outside of the trashcan. On 11/7/23 at 1:38 PM Resident #21 was observed in bed sleeping. Dried skin was peeling on his lips and he had contracted hands and foot drop. The display on the feeding pump was: Feed 70 mL/hr, 9060 Fed, 3262 Flush, Flush 50 mL every one hour. The feed level was at 375ml approximately and the water level was approximately at 800 mL. On 11/7/23 at 4:40 PM an interview was conducted with LVN A regarding the soiled dressing being on the tray with a clean dressing. She stated that she had messed up and that she knew the correct procedures. She stated she was focused on the feed and then noticed his dressing needed to be replaced. She stated she should have put the dirty dressing in her gloves and dispose of it and then re-washed her hands and finished the clean process. She added that the procedure was kind of quickly done. She stated she normally carried a trash bag with her to dispose of the soiled items She stated she was in a hurry and the area was not set up like it should have been. She stated that dirty items could touch the clean and could cause cross-contamination. On 11/7/23 at 4:51 PM an observation was made of the G-tube pump for Resident #21 and an interview was conducted with LVN A at this time. Observation of the pump display revealed the water flush was still set at 50ml every 1 hour and not 51 ml flush as ordered. LVN A stated she did not know why it was set at 50ml instead of 51 ml. At that time, she corrected the dosage of water flush to 51 ml on the pump. She added she had not noticed this error with the flush and had just hit the prime button when she reconnected the resident to the feeding. She stated the pump was set on 50 ml flush prior to her coming on shift at 6:00 AM (11/07/23). Regarding why the G-tube setting was on 50ml flush, she stated it must have been set by the previous shift. She added it was her responsibility to ensure it was set at the correct rate. Regarding what could result from the incorrect setting on the water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 18 of 45 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few flush, she stated luckily it was a small amount error, but if it were a higher rate, it could have affected the resident and possibly caused dehydration. She stated, that there had been no skills check or additional instruction regarding G-tubes. She added, the G-tube system used by Resident #21 was the first G-tube flush system of its kind that she had encountered. On 11/8/23 at 8:43 AM Resident #21 was observed on his air bed. The used G-tube flushing syringe was stored in a bag with the plunger inside the barrel and liquid was in the tip. There was white debris inside the syringe. On 11/8/23 at 10:23 AM an observation was made of Resident #21 asleep in bed and the G-tube pump was turned off. There was a G-tube flushing syringe in a bag hung on the pump pole. The documentation on the bag was 11/8/23 and the plunger was stored inside the barrel and the syringe was wet on the interior with white debris inside. On 11/8/23 at 11:44 AM an observation was made of agency LVN C reconnect Resident #21 to his G-tube pump. Upon entering the room there were 4 cups of water on the over bed tray table and the new bag of Isosource 1.5 cal formula was also on the over bed tray table. LVN C then used the same soiled flushing syringe that had been stored with the plunger in the barrel with debris inside. She used the flushing syringe to check the residual and she received 20 ml of residual in return and dispensed it back into the resident. She listened for bowel sounds and then flushed the G-tube with 15 mils of water using the same flushing syringe. She did not clean the flushing syringe after use and left it stored together with the plunger in the barrel and soiled. The water flush bag was hung, and the bag of formula was hung and connected to the resident. She placed the soiled flushing syringe in the same bag that it had been in and hung the bag on the pole for use. The flushing syringe had water/stomach contents in the tip of the flushing syringe. The screen on the pump displayed the following: 70 ml/hr Feed, 51 ml flush every 1 hour, 3566 flush, 9524 Fed. LVN C then placed the formula tubing cap on one of the hooks on the pump pole and the hook was not clean. On 11/8/23 at 12:03 PM an interview was conducted with LVN C regarding Resident #21's G-tube hanging. She stated the signature on the flushing syringe bag (LVN B) was from the night shift. She added, she was told by staff change out the flushing syringes every night. Regarding the storage of the plunger in the flushing syringe barrel, she stated, this was how she had seen them stored everywhere. Regarding the tubing cap being stored on the soiled pole she stated she could store it in a baggy instead. Regarding what could result from her actions related to the storage of the flushing syringe and the endcap for the feeding tube she stated there could be infection control issues. She added the flushing syringe was stored with the plunger in the barrel when she came on duty at 6:00 AM (11/08/23). Regarding any orientation that included G-tube flushing syringes, she stated that the facility did not go over proper storage of used flushing syringes prior to starting to work in the facility. On 11/8/23 at 12:11 PM an interview was conducted with the DON regarding G-tube procedures. Regarding how staff were instructed to store the used flushing syringes, she stated, they are changed daily, and packaging dated when opened. She added staff should rinse the flushing syringe out with water and store it in the bag. She added, the parts (plunger and barrel) should be stored together with the plunger in the barrel. Regarding dressing changes, she stated, the dirty items should have been tossed in the trash. The soiled should have gone in the trash and then the nurse should have washed her hands and donned gloves. The nurse should have then continued with the clean dressing . She added if staff placed the soiled items in the trash, they should have taken the trash out immediately or ideally bring their own trash bag in for the procedure. Regarding if she had conducted any in-services related to G-tube care, she stated not recently and that she just talked to staff about G-tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 19 of 45 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few procedures. Regarding why the situation occurred with the dressing change, she stated the nurse was just flustered. Regarding any monitoring she conducted related to G-tube services for residents, she stated for new staff, nursing administration checked them and then they checked what was given to the resident. She added nursing administration checked that all things go as ordered and conduct direct monitoring. Regarding what she expected staff to have done, she stated to follow policy and procedure. Regarding what could result from the actions observe related to G-tubes, she stated regarding not following the order, if it goes a long time, a resident could experience dehydration. Regarding the dressing changes there could be cross-contamination. Regarding the stored cap on the pole, it could be cross contamination. Regarding improper flushing syringe storage, there could be cross-contamination, an increase in bacterial growth and the resident could get sick. On 11/8/23 at 12:45 PM an interview was conducted with the Administrator regarding G-tube procedures observed. Regarding why he felt the situations occurred, he stated staff not following policy. Regarding what he expected staff to have done, he stated be familiar with the policy and follow procedures better. Regarding what could result from the G-tube issues observed, he stated residents could get an infection and not receive proper nutrition and lose weight. Record review of the facility policy, titled Gastrostomy/Jejunostomy Site Care, Level III, revised October 2011, revealed the following documentation, Purpose. The purpose of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Preparation. 1. Verify that there is a physician's order for the procedure. 3. Assemble equipment and supplies needed. Steps and Procedure. 2. Wash hands and dry thoroughly. 10. Discard disposable supplies in designated containers. Record review of the facility policy, titled Enternal Tube Feeding Via Continuous Pump, Level III, revise November 2018, revealed the following documentation, Purpose. The purpose of this procedure is to provide a guideline for the use of pump for enteral feedings. Preparation. 1. Verify that there is a physician's order for this procedure. General Guidelines. 1. Use aseptic technique when preparing or administering enteral feedings. 3. Check the enteral nutrition label against the order before administration. Check the following information. g. Rate of administration (ML/hour) . Steps In Procedure. 1. Placed equipment on the bedside stand or over bed table. Arrange the supplies so they can be easily reached. 2. Wash hands and dry thoroughly. 5. Check the label on the enteral formula against the physician's order. Initiate Feeding. 5. On the formula label .initial that the label was checked against the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 20 of 45 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 11/08/2023 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 0693 7. Discard disposable supplies in the designated containers. Level of Harm - Minimal harm or potential for actual harm 8. Clean reusable equipment according to the manufacture's instructions. 12. Remove gloves and discard into designated container. Residents Affected - Few 13. Wash your hands. Record review of the facility policy, titled Enteral, Feeding Syringes, Sanitization Of Reusable, Level II, revised March 2015, revealed the following documentation, Purpose. The purpose of this procedure is to guide the proper sanitizing of reusable enteral feeding syringes. Preparation. Assemble equipment and supplies needed. Equipment and Supplies. The following equipment and supplies will be necessary when performing this procedure . 4. Sixty (60) ML enteral feeding syringe. Steps in the Procedure. In the absence of manufactures, specific care and maintenance instructions, sanitize reusable enteral feeding syringes as follows. 4. Rinse 60 ml enteral feeding syringe with running water if the syringe had contact with stomach secretions or enteral feeding. 7. Disassemble the enteral feeding syringe. place syringes in bleach solution in the container. 8. Place a lid on the container. 11. Place syringe parts on top of the lid. 13. Shake moisture off of the container and sanitized items. 14. Place syringe parts inside the container. 15. Placed the lid on top . 16. When ready to use, rinse the syringe with fresh tap water. 17. Discard the syringe weekly or whenever obviously soiled or malfunctioning. Record review of a facility policy titled Enteral Feedings - Safety Precautions, Level III, revised November 2018, revealed the following documentation, Purpose. To ensure the safe administration of enteral nutrition. Preparation. 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified, and competent, in his or her responsibilities. 2. The facility will remain current and follow excepted best practices in enteral nutrition. General Guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 21 of 45 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 11/08/2023 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 0693 Preventing Contamination. Level of Harm - Minimal harm or potential for actual harm 1. Maintain strict aseptic technique at all times when working with enteral nutrition systems, and formulas. Preventing errors in administration. Residents Affected - Few 1. Check the enteral nutrition label against the order before administration. Check the following information. Rate of administration (ML/hour) . Record review of the facility policy titled Standard Precautions, revised October 2018, revealed the following documentation, Policy Statement. Standard precautions are used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation . 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. 2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision making in various clinical situations . Standard precautions include the following practices . 5. Resident care equipment. a. Resident care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucus membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments . c. Single use items are properly discarded . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 22 of 45 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 11/08/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 6 out of 30 (10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 10/31/23 revealed there were two RNs employed at the facility. Record review time sheet for DON dated 11/6/23 revealed no hours worked for 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23. Record review time sheet for RN A dated 11/6/23 revealed no hours worked for 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23. During an interview on 11/08/23 at 11:30 AM with the DON she stated she was currently the only RN employed. She stated she works Monday through Friday 08:00 AM to 05:00 PM. She stated they had to let one RN go and then the other RN gave her notice effective immediately. She stated they were advertising for RNs. She stated they do have contracts with agency, but she was not allowed to use for RN only LVN. She stated all request for agency must be approved and the request were usually denied. She stated they want agency out of the building, because they were not invested like the employees are. She stated the difference between and RN and LVN was the RN can do more than an LVN. She stated the RN has the critical thinking piece that LVNs don't have. She stated the potential negative outcome could be if something goes wrong and was missed could cause harm to the resident. She stated the worst-case scenario the resident could die. During an interview on 11/08/23 at 11:45 AM with the ADM he stated they currently do not have any RNs except for the DON. He stated they were advertising through corporate but was having a difficult time hiring an RN. He stated they do have contracts with agency but do not use them for RN coverage. He stated the difference between an RN and LVN was the LVN cannot do the same task as the RN. He stated the potential negative outcome could be harm to the resident by not picking up on changes in condition. He stated the RN have stronger assessment skills. Record review of the facility policy titled Staffing-RN coverage and licensed coverage, updated revealed the following: Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 23 of 45 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 11/08/2023 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 0727 Policy Interpretation and Implementation . Level of Harm - Minimal harm or potential for actual harm An RN is available for coverage 8 hours a day 7 days a week. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 24 of 45 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 11/08/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments on for 2 medication cart (South-hall Medication Cart and North-hall Medication Cart)) of 2 carts reviewed for storage and 1 treatment cart (Station 2) of 2 treatment carts. The facility failed to ensure two narcotic boxes for 1 medication cart was always locked. The facility failed to ensure that medications were properly labeled and stored properly. The facility failed to ensure treatment cart medications were stored in a secure locked manner, while unattended, for 1 of 2 treatment carts (Station 2). This failure could place residents at risk of having access to unauthorized narcotic medications and/or lead to possible harm, drug overdose, or drug diversions. Findings included: On 11/06/2023 at 4:07 pm, an observation and interview was done for medication cart check and medication pass for the south cart on south hall with LVN E. During the observation the narcotic box located inside of the medication cart was left unlocked with heavy duty tape on the outside to help open the door of the narcotic box. LVN E continued to leave the narcotic box unlocked while closing the medication cart. When asked about leaving the narcotic box unlocked LVN E stated that she just leaves it open because it makes it easier when she goes to give her medications. When LVN E was told that she could not leave the narcotic box unlocked, LVN E closed the box and then opened it again and closed the medication cart. LVN E continued to leave the narcotic box unlocked for the duration of the medication pass and gently closing the door to the narcotic box making sure to not completely close the narcotic box. On 11/6/23 at 5:27 PM a treatment cart was observed on Station 2 near the nurse station. The cart was unlocked and unattended near room [ROOM NUMBER]. On 11/6/23 at 5:28 PM an observation and interview were conducted with LVN A, charge nurse on Station 2. She stated she thought she locked the treatment cart. She further stated that inside of the treatment cart were insulin pens and the medications given to Resident #21 via G-tube. Observation of the cart interior revealed containers of resident ointments, insulin pens and medications for Resident #21 (pills). On 11/6/23 at 5:32 PM an interview was conducted with LVN A. LVN A stated the nurse and medication aide were responsible for ensuring the medications were stored in a secure manner. She added that the treatment cart should have been locked. Regarding what could result from medications not being secured properly, she stated residents could get into the treatment cart and medications and it could be dangerous for them. On 11/07/2023 at 8:36 am an observation of medication pass and medication cart check for north hall was conducted with MA. During the medication cart check, it was observed that two loose pills were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 25 of 45 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 11/08/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the area of the medication punch cards. The two medications were identified as lisinopril and Amlodipine 10 mg, located in the second drawer of the medication cart. It was observed that the MA's medication cart stored some fragrances along with the medications that was identified as Scentsy fresh 16 fl. Oz (apple cinnamon), and sure scents (Hawaiian scent) automatic refill 4.5 oz. During medication cart check it was observed that the north cart had expired medications listed as: calcium carbonate expired on 08/2023 (500 mg), albuterol sulfate for Resident #24, there was no label on the inhaler but there was a label on the box, but the box was open with the potential of the inhaler not secured. Symbicort 80/45 mcg was observed for Resident #32 with no label on the medication and not secured in the box. Observed Ventolin HFA 90 mcg for Resident #49 with no pharmacy label. Observed nasal decongestant OTC designated for Resident #43 with no pharmacy label. Observed Fluctuant 200/25 mcg for Resident #49 with no pharmacy label. On 11/07/2023 at 8:59 am an Interview was conducted with MA. MA stated that she does not know why there was loose pills on the cart and that she may have responsibility for the cart now, but it was also a shared cart. MA stated that when she assumes responsibility, she does check her cart but did not notice the two loose pills in her medication cart when she previously checked it. MA stated that the pink loose pill was definitely a lisinopril because she always gives this mediation, and it looked familiar to her. MA stated that the medication that was stored with an open box such as inhalers should be labeled on the medication and the box because if the medication was to fall out of the designated box, then they would not know whose medication and where their medication was located. MA stated that the negative potential outcome for having loose pills or no label on medications could be accidentally giving the wrong patient the wrong medication. MA stated that the negative potential outcome for giving a resident an expired medication would be the loss of potency and the resident would not be getting the medication that was required for them to have and possibly causing their health to decline. MA stated that she has been trained on medications labeling. MA stated that the training is randomly through in-services and are approximately held monthly. MA stated that the scents that were found on the cart during medication cart check was not hers but another MA that worked at the facility. MA stated they usually do not keep fragrances on the carts. MA stated that the negative potential outcome was that a resident could possibly ingest a chemical that they do not need to ingest and possibly affecting their health. MA stated that it goes back to the 5 rights of medications: the right patient, the right drug, the right time, the right dose, and the right route. On 11/07/2023 at 9:17 am an observation was completed of LVN E during medication pass. LVN E demonstrated to Surveyors that the narcotic box was left unlocked and there was heavy duty tape on the medication to help her to be able to lift the box door to the unlocked narcotics. LVN E demonstrated to the Surveyors that she had the key on her keychain that was kept in her pocket. LVN E demonstrated to Surveyors that the key fit the narcotic box and was able to successfully open the narcotic box. During the entire medication pass, LVN E left the narcotic box unlocked even after she had been asked about why she had left the narcotic box unlocked on several occasions. LVN E continued with the medication pass and gently lowering the lid to the narcotic box down so that she did not lock the box. LVN E demonstrated to the Surveyors that the box would lock and open with the key when she was asked by Surveyors to lock the box and then to open the box with the key. On 11/07/2023 at 9:17 am an Interview was conducted with LVN E. LVN E stated that she was aware that there was tape on the narcotic box and that the narcotic box was open and not locked. LVN E stated that the reason that there was tape on the narcotic box was because it was hard to open the box every time, she needed to get a narcotic out of the box. LVN E stated that the protocol for narcotic box on the medication cart was that the narcotics should be double locked. LVN E stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 26 of 45 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 11/08/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some if a medication cart was to be left unlocked then a resident could accidentally get a narcotic. LVN E stated that the reason she just leaves the narcotic box open was because it was too heavy to open and makes it difficult, but she was aware that she was supposed to have it locked at all times. LVN E stated that she was just doing it to save time to get to her medications quicker. Interview with the Administrator on 11/07/2023 at 10:40 am., the Administrator stated that the policy states that the medication cart should be double locked, and the narcotics were to be locked in a separate compartment within the locked medication cart. The Administrator stated that his expectations for all employees that have assumed responsibility for the medication cart was to have the medication cart locked at all times when not getting medications out of the medication cart. The Administrator stated that in-services has been completed for narcotics but not on locked carts with narcotics. The Administrator stated that the negative potential outcome for not locking narcotics within the medication cart was that a resident could potentially get hurt by overdosing and, It could be really bad, and it should be locked. The Administrator stated that in-services for medication administration has been completed by the DON. The Administrator stated that the carts should not have loose pills and that the day that the State came into the building he advised the staff to check the carts to make sure they were in good shape. The Administrator stated that for the labeling that all medication should be labeled correctly and anytime there was an unlabeled medication or a medication that was not labeled correctly, not to take it, and send it back to the pharmacy. The Administrator stated that the policy states that the medication must be labeled. The Administrator stated that his expectations was for an open boxed inhaler should be labeled on the medication and the box because if the medication came out of the box and the medication was not labeled then the wrong resident could be getting the wrong medication. The Administrator stated that this goes back to the 5 rights of medication. The Administrator stated that the 5 rights of medication were: the right patient, the right drug, the right time, the right dose, and the right route. On 11/8/23 at 11:07 AM an interview was conducted with the DON related to the unlocked unattended treatment cart. She stated staff were instructed to lock their carts when not with it. Regarding why the situation occurred, she stated more than likely the person was in a hurry and forgot to lock it. Regarding what she expected of staff, she stated staff should always lock the cart. Regarding whom was responsible for ensuring medications were secured on the carts, she stated the nurse on duty, DON and ADON. She added that spot checks of carts were conducted. Regarding what could result from medications not being secured on the medication or treatment carts, she stated residents could get into the carts and eat creams and take pills. DON stated that staff has been in-serviced on medications through in-services and she will make sure to complete another in-service. Record Review of facility provided policy, labeled, Storage of Medication, date revised in November 2020, revealed: Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 27 of 45 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 11/08/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. Residents Affected - Some 4. Drug containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy destroyed. 5. Hazardous drugs are clearly marked and stored separately from other medications. 6. Compartments (including, cut not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left attended. 8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. A). Controlled medications that are part of a single unit dose distribution system may be stored with non-controlled medications when the supply is minimal, and shortages are readily detectable. Record Review of facility provided policy, labeled, Administering Oral Medications, date revised on October 2010, revealed: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. General Guidelines: Follow the medication administration guidelines in the policy entitled Administering Medications. Steps in the procedure: 7. Check the expiration date on the medication. Return any expired medications to the pharmacy. 10. Confirm the identity of the resident 11. Explain the procedure to the resident Record Review of facility provided policy, labeled, Controlled Substances, date revised in April 2019, revealed: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 28 of 45 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 11/08/2023 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 0761 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm 6. Keys to controlled substance containers are kept on a single key ring separate from any other keys. Residents Affected - Some Record Review of facility provided In-Services, labeled, Medication, dated on 03/27/2023 revealed under Summary of Subject Matter: 10 rights of Medication Administration. 12 employees signed and attended. Record Review of facility provided In-Services, labeled, Random Cart Checks, dated on 06/ 05/2023 stated under Summary of Subject Matter: Random checks for narcotics and disposals of medication must be done daily. Shows 7 employees signed and attended. Record Review of facility provided In-Services, labeled, Weekly cart audits must be performing along with narcotic counts with medication and nurses, dated on 06/07/2023 revealed that 6 employees signed and attended. Record review of the facility policy, titled Storage of Medications, revised November 2020 revealed the following documentation, Policy Heading. The facility stores, all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation. 1.Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Record Review of CMS Appendix PP State Operations Manual Medication Access and Storage last revised 02/03/2023, revealed A facility is required to secure all medications in a locked storage area and to limit access to authorized personnel .During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 29 of 45 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 11/08/2023 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1)The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean. 3) The facility failed to ensure staff washed their hands in a sanitary manner. 4) The facility failed to ensure raw meat was thawed in a safe and sanitary manner. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observations and interviews were made during a kitchen tour on 11/06/23 that began at 9:17 AM and concluded at 10:10 AM: A large tube of frozen hamburger meat in a pan on the food preparation counter. It was not thawing in running water. There was no water in the pan. The drink gun spout had a buildup of syrup and was soaking in brown colored water in a container near the drink dispensing machine. Observation of the fryer revealed that the interior cabinet had a buildup of grease and food debris. The exterior also had recent debris buildup. The center basin of the three-compartment sink had raw chicken thawing in standing water. There was no running water on it. Dietary staff A was observed separating the frozen raw chicken in the 3-compartment sink. On 11/6/23 at 9:40 AM, the Dietary Manager washed her hands and then dried her hands with a paper towel. She then touched the paper dispenser handle with her bare hands. She dispensed more paper towels and dried her contaminated hands again. She then continued food related duties. There was a box of Styrofoam plates stored on the floor in the Dietary Managers office. During an interview on 11/6/23 at 9:55 AM, Dietary staff A stated the raw chicken in the three-compartment sink had been frozen since 6 AM this morning (11/06/23). - The following observations were made during a kitchen tour on 11/06/23 that began 10:55 AM and concluded at 12:10 PM: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 30 of 45 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 11/08/2023 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 The large partially frozen tube of raw hamburger meat was still thawing in a pan on the prep table. There was blood pooling in the pan. During an interview and observation on 11/6/23 at 10:59 AM, Dietary staff A stated that she had three purées to prepare. She placed mixed vegetables in a pan and cooked chicken in another pan. She took the mixed vegetables and placed them in the processor pot, which was still wet from on the interior. She placed the mixed vegetables in the processor, puréed it and then placed it in a pan. She took the processor parts to the dishwasher. She then went to the hand sink to wash her hands. She first dispensed paper towels from the paper towel dispenser and place them under her arm. She then washed her hands and dried them with the paper towel that was under her arm.She dispensed more paper towels from the dispenser, dried her hands and then took that towel and turned off the water. She then retrieved the clean processor from the dishwasher. She then donned gloves and took temperatures of cooked chicken that had come out of the oven. She used her gloved hands and a spatula to place cooked chicken in a pan. The Dietary Manager was observed washing her hands . After washing her hands, she used her bare hands and dispensed the towels. She then dried her hands and used the paper towel to turn the water off. Dietary staff B was observed, washing his hands . After washing his hands, he dried them with a paper towel. He then turned off the water with the paper towel. He then dispensed more paper towels while still holding the soiled paper towel. He then used both the soiled and clean paper towels to dry his hands. He continued with dietary duties. Dietary staff A retrieved the processor parts from being washed and assembled them in the processor. The Dietary Manager pulled the blade out of the processor with her bare hand to show the blade. The base of the blade and interior of the processor pot was not clean and had food debris. Dietary staff A retrieved a second set of processor parts, which was wet on the interior also (blade and lid). She then placed chicken in the processor and puréed the chicken. There were cartons of shakes stored in a container of undrain ice at the service counter. Dietary staff B prepared the puréed bread pudding and place it in the processor which was wet on the interior and had a wet blade and puréed it. He then placed the purée in bowls. The raw partially thawed tube of hamburger meat was still in the pan on the prep table at as of 11:44 AM on 11/06/23. Record review and observation of the dishwasher sanitizer labeled Auto Chlor Super 8 revealed the following documentations, Directions for Use. Sanitizing Food Contact Surfaces. 5. Drain and allow equipment or utensils to air dry. - The following observations and interviews were made during a kitchen tour on 11/06/23 that began at 5:12 PM and concluded at 5:25 PM: The drink gun was soaking in brown water. On 11/6/23 at 5:17 PM an interview was conducted with Dietary staff A regarding the meat used for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 31 of 45 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 11/08/2023 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 the sloppy joe's which was hamburger meat. She stated, the Sloppy Joes were made from the hamburger that was out and thawing on the prep table. There was a box of Styrofoam plates on the floor in the Dietary Managers office. - The following observations were made during a kitchen tour on 11/07/23 that began at 8:34 AM and concluded at 8:42 AM: The drink gun was soaking and submerged in water in a container. There was a set of keys stored on the prep table next to a box of gloves and bags of buns. On 11/7/23 at 2:42 PM an interview was conducted with Dietary staff A regarding issues in the kitchen. She stated she should have air dried the processor per training. She also stated usually she places the meat in a bucket and run water over it to thaw it. She added that the dietary department had received an in-service on thawing last year. She further stated that she had been trained and in-serviced on the correct way to wash your hands (not to recontaminate them). She stated contamination could result from her actions in the kitchen; thawing improperly could make someone sick. She stated staff getting too relaxed was why these problems occured. On 11/8/23 at 10:37 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. She stated, she had conducted dietary in-services recently. She stated, normally staff soak the drink gun at the end of the shift. The next morning at approximately 10:30 or 10 AM it is taken out of the soaking solution. She added staff had been in-serviced last year about the air drying process for the processor. She stated on thawing, Dietary staff A got nervous; she gets worked up. She should have thawed the chicken out the day before. The ground beef should have been under running water. She stated staff had been taught the correct steps for handwashing. She stated she was not sure why staff performed handwashing incorrectly. Regarding what she expected staff to have done, she stated, to follow procedures. She stated Dietary Manager and the staff was responsible for ensuring that dietary duties were conducted correctly. Regarding what type of monitoring system she had that ensured staff conducted dietary duties correctly, she stated, she conducted kitchen walk-throughs and had a cleaning scheduled. She added she monitored after each shift. She stated new employees were trained for three days and after that, she asked staff if they need more training. If so, they will train more. She stated residents could get sick as a result of the dietary problems observed. On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated, staff were not paying attention with handwashing and not following policies regarding thawing and using the wet processor. He stated staff should have immediately correct the situation and follow procedures. He stated the Dietary Manager was responsible for ensuring that correct actions were taken in the dietary department. He stated the spread of germs and diseases could result from the problems observed in the dietary department. On 11/8/23 at 12:54 PM interview and observation in the dining room. It was noted that there was a gallon container of milk stored in a pan of undrained ice. The ice was melting in the pan. The Dietary Manager stated that she would begin to use a drain type pan for iced down foods. Record review of the In-Service Training Report dated 12/8/22 revealed that an in-service was conducted with the Subject: How to thaw out meat. Summary of Subject Matter revealed the following, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 32 of 45 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 11/08/2023 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 Please ensure that when thawing out meat, we are putting the meat in the sink with running cold water or pull the meat out the previous day. Further record review of the report revealed that Dietary staff A attended this in-service. Record review of the In-Service Training Report dated 10/12/23 revealed a Subject: Handwashing. Those attending the in-service were the Dietary Manager, Dietary staff A, and Dietary staff B. Record review of the facility policy, titled Sanitization, revised October 2008 revealed the following documentation, Policy Statement. The food service areas 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 [NAME] free from brakes, corrosion's, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solution. 10. Food preparation, equipment, and utensils that are manually wash will be allowed to air dry whenever practicable. Record review of the facility policy, titled Food, Preparation and Service, revised April 2019 revealed the following documentation, Policy Statement. Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. Food Preparation Area. 5. Food preparation staff here to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Thawing Frozen Food. 1. Foods will not be thawed in at room temperature. Thawing procedures include: a. Throwing in the refrigerator in a drip proof container; b. Completely submerged item in cold, running water, (70°F or below) that is running fast enough to agitate and remove loose ice particles; c. Thawing in a microwave oven, and then cooking and serving immediately; or d. Thawing is part of a continuous cooking process. Food service slash distribution . 4. Food and nutrition services staff, including nursing services personnel, wash their hands before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 33 of 45 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 11/08/2023 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 serving food to residents. Employees also wash their hands after collecting soil plates and food waste prior to handling food trays . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 34 of 45 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 11/08/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 2 dumpsters (west) and dumpster area. Residents Affected - Few The facility failed to maintain the dumpster/refuse disposal containers and area in a manner that effectively prevented the harborage and attraction of pest. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. The findings include: On 11/6/23 at 10:02 AM an observation was made at the dumpster area. There was a mattress with a torn cover on the ground behind the two dumpsters. There was trash scattered around the dumpster area that was approximately in an L shape pattern of more than 20 feet each way behind the dumpsters. The area had trash, which included cups, weeds, shopping cart, and the mattress with the torn cover. There was also a large amount of trash along the fence line in the area that included trash and cigarette butts. Behind the oxygen storage building that was adjacent to the dumpsters there was an approximately 5' x 8' area filled with trash and paper, cups, etc. On 11/6/23 at 2:40 PM an observation was made of 1 of 2 dumpsters (west) that was actively leaking in two areas at the bottom front area of the dumpster. The waste water was pooling on the concrete slab in an approximately a 2' x 3' area. There was trash still in the area as before, which included a mattress with a torn cover, shopping cart, scattered bottles, gloves, and other debris. The leaking wastewater was trailing approximately 16 feet from the dumpster. The immediate area of pooling wastewater was approximately 2 feet to 4 feet away from the source of the leak. Observation on 11/7/23 at 8:43 AM revealed one of two dumpsters (west) was leaking from the bottom front and waste water was pooling in an approximately 6'x 3'area. There was still trash, weeds, mattress, shopping cart, and other scattered trash in the area. On 11/7/23 at 9:30 AM an interview and observations were conducted with the Maintenance Supervisor. He stated, he had been trying to get out to the dumpster area, but he was busy with other facility duties. He added he tried to get out to the dumpster area last week to clean up. He stated, the dumpster was probably leaking since he was hired in January 2023. He added that he had not received no orientation related to the grounds and dumpster maintenance. He stated, all he was aware of was he needed to keep the dumpster lids closed. He stated trash situation was caused by trash from the dumpster coming out when it was dumped by the dumpster company. He added the leaks were due to the dumpsters being old. He tried to come out one time a week and clean the area. He stated he was not sure what could result from the dumpster and trash accumulation situation. He stated the area should have been sprayed down and cleaned. Observation of the dumpster area revealed the dumpster was still leaking and trash was still in the dumpster area which included the mattress, shopping cart, loose debris and trash. He stated it was the Maintenance Supervisor's responsibility to ensure the grounds and dumpster were maintained in a sanitary manner. On 11/8/23 at 9:04 AM an observation was made at the dumpster area and one of two dumpsters (west). The west dumpster had one of two side doors open. There was wastewater pooling at the front of the dumpster where it had leaked. There was still trash, shopping cart, broken ceramics, and a mattress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 35 of 45 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 11/08/2023 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 0814 surrounding the dumpster area. Level of Harm - Minimal harm or potential for actual harm On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated staff were not making daily rounds and they needed to make rounds of the grounds. He stated staff should have picked up the stuff and should have reported the leaking of the dumpster. He stated the Maintenance Supervisor was responsible for ensuring that the grounds and dumpsters were maintained in a sanitary condition. He stated infection control, bugs, and flies attracted to the area could result from the grounds and dumpster problems observed. Residents Affected - Few Record review of the facility policy, titled Grounds, revised May 2008, revealed the following documentation, Policy Statement. Facility grounds shall be maintained in a safe and attractive manner. Policy Interpretation and Implementation. 1. Maintenance shall be responsible for keeping the grounds free of litter. 3. Areas around the building (i.e., sidewalks, patios, gardens, etc.) shall be maintained in a safe and orderly manner at all times. Record review of the facility policy, titled Maintenance Service, revised December 2009, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy interpretation, and implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: . h. Maintaining the grounds, sidewalks, parking, lots, etc., in good order. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 10. Maintenance personnel shall follow Established safety regulations to ensure the safety and well-being of all concerned . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 36 of 45 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 11/08/2023 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 and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. 2 of 2 staff (LVN E and MA) and 1 of 22 Residents Affected - Some LVN E and MA failed to implement effective handwashing techniques during medication pass. The facility failed to ensure that dressing change procedures were conducted in a sanitary manner for Resident #21. These failures could affect residents and staff members by placing them at risk for the transmission of communicable diseases, and infections. Findings include: On 11/7/2023 at 8:22 am an observation was completed with MA during medication pass. MA did not wash hands or use hand sanitizer prior to preparing medications and did not use a clean paper towel when she washed hands prior to administering the medications to resident. MA turned on water and put soap in hands, washed her hands for 23 seconds, rinsed hands, grabbed a clean paper towel, and proceeded to dry hands, and used the same paper towel that she used to dry hands and turned off the faucet, threw paper towel in the trash. On 11/7/2023 at 8:47 am an Interview was conducted with MA. MA stated that she has been trained in infection control practices/ hand washing. MA stated that she does realize that she forgot to wash her hands before preparing medications and was not thinking. MA stated that she did not know that she could not use the dirty towel to turn off the faucet. MA stated, I guess it makes sense to use a clean paper towel and not the dirty one to turn off faucet. MA stated that the facility has conducted in-services for hand washing and they have one usually monthly. MA stated that the negative potential outcome was that by not washing hands or washing hands properly then it could spread infections. On 11/7/2023 at 9:17 am an observation was made with LVN E during medication pass. LVN E went into the resident room to administer medication and washed hands but used a dirty towel to turn off the faucet and only washed her hands for 9 seconds. On 11/7/2023 at 9:23 am an interview was conducted with LVN E. LVN E stated that she has been trained in infection control practices/ hand washing. LVN E stated that a hand washing skills check has been done in the facility but was unsure of the timeframe. LVN E stated that in-services were done for hand washing probably monthly. LVN E stated that she had been taught that she should use the dirty towel to turn off the faucet to save on paper towels. LVN E stated that the negative potential outcome for not using a clean towel or failing to wash hands prior to medication administration was cross contamination. On 11/7/2023 at 10:40 am an Interview was conducted with the Administrator. The Administrator stated that he does expect the staff to use hand hygiene before preparing medications and after administering medications. The Administrator stated that anytime you come into contact with a resident, you need to perform hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 37 of 45 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 11/08/2023 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 the Order Summary Report dated 11/6/23 for male Resident #21 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of dysphagia oropharyngeal phase (swallowing disorder), gastrostomy status (nutrition delivered through abdominal wall), contracture, unspecified, joint (reduced joint flexibility), personal history of traumatic brain injury (brain injury), anoxic brain damage, not elsewhere, classified (loss of oxygen to the brain), gastrostomy, complication, unspecified (difficulty with nutrition delivered through abdominal wall), moderate protein calorie malnutrition (malnutrition), and quadriplegia, unspecified (paralysis of all 4 limbs). Further record review of the Order Summary Report revealed the following orders: Clean area around peg to with NS, pat dry, cover with split 4 x 4 gauze, one time a day related to quadriplegia, unspecified: gastrostomy complication, unspecified. Clean area around peg tube with NS pat dry, apply [NAME] zinc and cover with split 4 x 4 gauze. Order status active. Order date 6/12/23. Start date 6/13/23. Record review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed that the resident had no BIMS score and was documented as severely impaired cognitively - never/rarely made decisions. Further record review of this MDS documented the resident had Active Diagnoses that included quadriplegia, malnutrition, and aphasia (difficulty speaking). Additional diagnoses included gastrostomy complication, unspecified, indicated by ICD code K94.20. Record review of the current care plan current for Resident #21 revealed the following Focus. (Resident #21) requires tube feeding R/T malnutrition dysphagia, weight expected to fluctuate R/T TF and dependent edema secondary to quadriplegia. Isosource 1.5 at 70 ML/HR HR X 20 hours. Flush with 30 ML before and after meds. Change syringe every night. Check residual every shift, hold, if 100 or above for one hour. Peg site care daily. Water flush 51ML/HR X 20 hours continuous. Pump at 12 PM and off at 8 AM. May use Coca-Cola to unclog G-tube2 PRN. Folic acid. Date initiated: 9/15/16. Revision on: 8/2/23. The Goal included, He will remain free of side effects or complications related to tube feeding through review date. Date initiated: 9/15/16. Revision on: 4/24/23. Target date: 1/21/24. Interventions/Tasks included, Checked for tube placement and gastric contents/residual, volume per facility protocol and record. Hold feed times one hour, if greater than 100 cc aspirate. Date initiated: 9/15/16. Revision on: 9/15/16. He needs total assistance with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 9/15/16. Revision on: 9/15/16. Provide local care to G-tube site as ordered and monitor for S/SX of infection and/or skin breakdown. Report site problems to MD. Date initiated: 9/15/16. Revision on: 12/29/16. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 9/15/16. On 11/7/23 at 11:58 AM an observation and interview were conducted with LVN A as she reconnected Resident #21 back to the G-tube pump and changed his G-tube dressing. After completing the reconnection of the resident to the G-tube pump, LVN A removed the soiled dressing from the G-tube site and removed her soiled gloves and placed them on the same tray where there was a clean dressing to be placed on the G-tube site of the resident. She cleaned the site and placed clean dressings back on the G-tube site. Regarding why she had placed the soiled gloves and dressings on the tray with the clean dressing, she stated, she was trying to get the dressing on the resident's G-tube site. She further stated that normally she did not place the soiled dressings and gloves on the same tray with the clean items. She added this was not the ideal way of performing the procedure by placing clean and soiled items on the same tray. She added she did place the soiled dressings and gloves near the dirty cups. Prior to leaving Resident #21's room the LVN tossed all the soiled gloves and dressings and trash (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 38 of 45 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 11/08/2023 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 loosely and unbagged in the room trashcan that was on the A bed side. This resulted in a soiled glove from the treatment hanging on the outside of the trashcan. On 11/7/23 at 4:40 PM an interview was conducted with LVN A regarding the soiled dressing being on the tray with a clean dressing. She stated that she had messed up and that she knew the correct procedures. She added she was focused on the feed and then noticed his dressing needed to be replaced. She stated she should have put the dirty dressing in her gloves and dispose of it and then re-washed her hands and finished the clean process. She added that the procedure was kind of quickly done. She stated she normally carried a trash bag with her to dispose of the soiled items. Regarding why the dressing change issue happened, she stated she was in a hurry and the area was not set up like it should have been. Regarding what could result from her dressing change actions, she stated that dirty items could touch the clean and could cause cross-contamination. On 11/8/23 at 11:07 AM an Interview was conducted with the DON regarding infection control practices. The DON stated that she does expect staff members to properly wash hands before, during, and after resident care and before preparing medications. The DON stated that she has completed skills checks for hand washing and will provide that documentation. The DON stated that the skills checks were provided every three months. The DON stated that the negative potential outcome for not washing hands or using a dirty towel to turn off the faucet would cause one to spread germs and or infections. The DON stated that she will provide and in-service on hand washing. On 11/8/23 at 12:11 PM an interview was conducted with the DON regarding G-tube procedures. Regarding dressing changes, she stated, the dirty items should have been tossed in the trash. The soiled should have gone in the trash and then the nurse should have washed her hands and donned gloves. She then should have continued with the clean dressing. She added if staff placed the soiled items in the trash, they should have taken the trash out immediately or ideally bring their own trash bag in for the procedure. Regarding if she had conducted any in-services related to G-tube care, she stated not recently and that she just talked to staff about G-tube procedures. Regarding why the situation occurred with the dressing change, she stated the nurse was just flustered. Regarding any monitoring she conducted related to G-tube services for residents, she stated for new staff, nursing administration checked them and then they checked what was given to the resident. She added nursing administration checked that all things go as ordered and conduct direct monitoring. Regarding what she expected staff to have done, she stated to follow policy and procedure. Regarding what could result from the actions observe related to G-tubes, she stated there could be cross-contamination concerning the dressing change problems. On 11/8/23 at 12:45 PM an interview was conducted with the Administrator regarding G-tube procedures observed. Regarding why the situation occurred, he stated not following policy. Regarding what he expected staff to have done, he stated be familiar with the policy and follow procedures better. Regarding what could result from the G-tube related issues observed, he stated residents could get an infection. Record Review of the facility policy titles, Infection Control date Revised in October 2018 revealed: Policy Statement: The facility's infection control policies and practices are intended to facilitate maintaining a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 39 of 45 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 11/08/2023 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 safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objective of our infection control policies and practices are to: a). prevent, detect, investigate, and control infections in the facility. B). maintain a safe, sanitary, and comfortable environment for personnel, resident's visitors, and the general public. Record Review of the facility policy titles, Infection Control and Pr3evention date Revised in 2016 revealed: Hand Hygiene: proper hand hygiene is one component of standard precautions. It refers to hand washing with soap and water or the use of an alcohol-based rub, commonly abbreviated ABHR. Clean hands are the single most important factor in preventing the spread of healthcare associated infections. It stops the spread of infectious agents through direct and indirect contact. Stand back from the sink so you do not contaminate your clothing by splashing water or by touching the side of the sink. Wet your hands thoroughly. Apply the amount of soap recommended by the manufacturer to your hands. Lather the soap over the top and bottoms of your hands, fingers, and wrists using quick motions. Interlace your fingers to clean between them. Clean your fingernails by rubbing them against the palm of your other hand to force soap under the nails. According to the CDC (2002), you should lather the soap over all surfaces of your hands and fingers for at least 15 seconds. However, your organization's policy may specify a longer time for hand washing. Rinse your hands well under running water keeping your fingertips pointed downward. Do not shake water from hands. Dry your hands thoroughly with a disposable towel. Drop the towel in a trashcan without touching the container. Then use another disposable towel to turn off the faucet. According to the World Health Organization (WHO, 2009). The entire hand washing process should take 40-60 seconds to complete. As with hand washing, it's important for you to follow the proper procedure when using ABHRs as well. First, make sure that the product your using is approved by your organization. Some ABHRs on the market are not alcohol-based and therefore should not be used. Apply the amount of product recommend by the manufacturer to the palm of one hand then spread the product by rubbing your hands together until your hands are dry. As with hand washing, be sure to cover all surfaces of the hands and fingers including between the fingers. Record Review of the facility policy titles, Handwashing/Hand Hygiene date Revised in August 2019 revealed: Policy Statement: This facility considered 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. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based rub, etc.) shall be readily accessible and convenient for staff use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 40 of 45 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 11/08/2023 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 to encourage compliance with hand hygiene policies. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations. A0. When hands are visibly soiled, B). After contact with a resident with infectious diarrhea including, but not limited to infectious caused by norovirus, salmonella, shigella, and C. difficile. 7. A). before and after coming on duty, b). before and after direct contact with residents, c). before preparing or handling medications, h). before moving from a contaminated body site to a clean body site during resident care, i). after contact with a resident's intact skin, j). after contact with blood or bodily fluids. M). after removing gloves. Washing hands: 1. Wet hands first with water, the apply an amount for product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off faucet. 5. Avoid using hot water, because repeated exposure t hot water may increase the risk of dermatitis. Performing Hand Hygiene. In order to be effective, you must follow the proper procedure when washing your hands. First check that you have enough soap and disposable towels. Next, turn on the faucet and make sure the water temperature is warm. Keep the water running so you do not contaminate your hands by repeatedly turning the faucet on and off. Record review of the facility policy titled Standard Precautions, revised October 2018, revealed the following documentation, Policy Statement. Standard precautions are used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation . 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. 2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision making in various clinical situations . Standard precautions include the following practices . 5. Resident care equipment. a. Resident care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucus membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments . c. Single use items are properly discarded . Record review of the facility policy, titled Gastrostomy/Jejunostomy Site Care, Level III, revised October 2011, revealed the following documentation, Purpose. The purpose of this procedure are to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 41 of 45 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 11/08/2023 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 promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Preparation. 1. Verify that there is a physician's order for the procedure. 3. Assemble equipment and supplies needed. Steps and Procedure. 2. Wash hands and dry thoroughly. 10. Discard disposable supplies in designated containers. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 42 of 45 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 11/08/2023 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area in 5 of 11 resident rooms (104, 107, 116, 119 and 120) on Station 2 (East wing). Residents Affected - Some 1)The facility failed to ensure that 5 of 11 resident rooms had operable call systems at the bedroom and toilet. These failures could place residents at risk of not receiving assistance when needed. The findings include: On 11/6/23 at 11:18 AM an interview was conducted with Maintenance Supervisor. He stated sometimes the facility had problems with the call system. Repairmen have told the facility in the past that parts for the system cannot be obtained because they stopped making them. On 11/6/23 at 3:25 PM an interview was conducted with LVN A. She stated that some of the call lights do not illuminate at the Station 2 nurses station call board. On 11/6/23 at 3:26 PM an interview was conducted with CNA A regarding the call system indication board at the Station 2 nurses station. She stated, not all of the call board lights illuminate. Observation on 11/6/23 at 3:31 PM in room [ROOM NUMBER], revealed Resident #21 was in the B bed. The resident had an activation pad type call system, and when pressed would not stay on. The call system shut off as soon as pressure was not placed on the pad. Observation on 11/6/23 at 3:16 PM revealed when a call was registered from room [ROOM NUMBER] from either A or B bed or the bath there was no light illuminated at the nurse station call board. There was an audible sound, and the dome light was functioning. Observation on 11/7/23 at 8:23 AM revealed there was a call registered from room [ROOM NUMBER] and there was no light illuminated for 107 at the nurse station. The dome light illuminated and there was an audible sound. On 11/7/23 at 8:25 AM an interview was conducted with the Maintenance Supervisor regarding the call system. He stated, some light up and some don't. It's been like that since January (2023) when he was hired. He added he replaced the bulbs at the nurse station call board and they did not illuminate; he replaced six or seven of them. He stated those rooms that did not illuminate at the nurse call board were rooms 100, 102, 107, 110, and 116. He added there were three or four other ones that also did not illuminate. He stated the Call System Vendor was located out of town and it would take a while for them to come to the facility. He further stated the Call System Vendor had recommended the call system be replaced, then sent in a quote to have it repaired approximately 4 or 5 months ago. He stated the company was given a list of rooms and restrooms that needed repair. He stated, he checked the system one time a month, when it comes up on TELS online maintenance scheduling and documentation system. He added he goes checked each room. Regarding whom was responsible for ensuring that the call system worked, he stated that he was. He stated, the facility would move residents to rooms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 43 of 45 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 11/08/2023 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that had working call systems and would call the Call System Vendor to repair it. He added residents may not get the help they needed due to the partially functioning call system. On 11/7/23 at 9:30 AM an interview was conducted with the Maintenance Supervisor. Regarding why part of the call system was not functioning correctly, he stated, he could not get parts for the system. He added he was not familiar with the nurse call panel system. He stated he had called the Call System Vendor to repair it. He further stated he was not provided training on this call system. Observation on 11/7/23 at 10:44 AM revealed a call was registered from room [ROOM NUMBER]. The dome light was illuminated at the room, and the sound emitted when a call was placed. There was no light at the nurses station call board indicating room [ROOM NUMBER]. During an interview with LVN A on 11/7/23 at 10:44 AM, she stated staff had been complaining about the call system not fully functioning since day one. No specific date was provided. Observation on 11/7/23 at 11:35 AM in room [ROOM NUMBER], the call light was tested and there was no light illuminated at the nurse's station call board for room [ROOM NUMBER]. This was when a call was initiated from the bedroom or bath. A sound was emitted, and dome light illuminated. On 11/7/23 at 4:51 PM an observation and interview was made of Resident #21 in room [ROOM NUMBER]. LVN A pressed the resident's call pad, and it would not stay on. LVN A revealed she was not aware of this call pad not fully functioning. Observation on 11/8/23 at 8:44 AM revealed the call pad in room [ROOM NUMBER] still would not stay on once pressed. On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. Regarding why the call system was not fully functioning on Station 2, he stated the facility had worked on it and the call system was old. He added the system had been worked on a lot. Regarding what he expected staff to have done, he stated double check the call system and see that it was working. Regarding whom was responsible for ensuring that the call system worked properly, he stated that it was the Maintenance Supervisor. Regarding what could result from the call system not being fully functional, he stated residents may not be taken care of. Record review of the invoice from the Call Repair Vendor revealed and invoice dated 6/27/23 which documented, Notes. Repaired nurse call on southside of facility. Record review of the facility policy, titled Call System, Resident, revised September 2022, revealed the following documentation, Policy Heading. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation, and Implementation. 1. Each resident is provided with a means to call staff directly for assistance from her his/her bed, from toileting/bathing facilities, and from the floor. 3. The resident call system remains functional at all times. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 44 of 45 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 11/08/2023 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 0919 care plan. Level of Harm - Minimal harm or potential for actual harm 5. The resident call system is routinely maintained and tested by the maintenance department. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 45 of 45