Health inspection·June 9, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #19's face sheet dated 6/8/2023 revealed resident was a [AGE] year-old female whose diagnoses included: malignant neoplasm of vertebral column (cancer of the spine), complications after genitourinary (reproductive) surgery, muscle wasting and atrophy (shrinkage), cognitive communication deficit, hyperglycemia (high blood sugar), lack of coordination, abnormalities of gait and mobility, ataxia (loss of coordination), anxiety disorder, gastro-esophageal reflux disorder, quadriplegia, major depressive disorder, c4 level cervical spinal cord, malignant neoplasm of brain (cancer). Record review of MDS assessment for Resident #19 dated 03/31/23 indicated a BIMS of 14. Record review of Resident #19's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station. On 6/8/23, observation and at 7:49 AM revealed Resident #19 sitting in her wheelchair in her room. Resident #19 stated lighter was in room and a red lighter was observed to be on Resident #19's bed. In an interview on 6/8/23 at 7:49 AM with Resident #19, resident stated the lighter was in her room even though Resident #19 knew it was not supposed to be there. Resident #19 indicated that they were at the nurse's station. Resident #19 stated that assistance was needed to go smoke as Resident #19 was not able to transport independently outside. Record review of Resident #19's chart shows smoking assessment where Resident #19 is unable to smoke independently and uses assistive devices. Resident #20 Record review of Resident #20's face sheet dated 6/8/23 revealed a [AGE] year-old woman admitted into the facility on 8/26/2019. Resident #20 had diagnoses: morbid obesity, generalized anxiety disorder, heart failure, hypercholesterolemia (high cholesterol), schizoaffective disorder; depressive type, Type 2 Diabetes, nicotine dependence, and schizophrenia. Record review of Resident #20's care plan dated 5/16/23 revealed a focused goal of smoking without assistance. Record review of Resident #20's MDS assessment dated [DATE] revealed that resident had a BIMS score of 11 indicating cognitively intact. Resident #20 needed minimal/supervising assistance with areas of daily living. Record review of Resident #20's smoking assessment dated [DATE] revealed that resident smoking materials will be kept at nurses' station. Interview and observation with Resident #20 on 6/8/23 at 7:36 AM revealed that Resident #20 was allowed to smoke alone. Resident #20 showed smoking materials ofa blue lighter in left hand. Resident #20 also advised that cigarettes were kept at the medication cart. Observation on 6/8/23 at 11:35 AM showed two packages of Montego Gold 100's-one opened and one unopened. Observation on 6/8/23 at 11:48 AM, LVN E opened the medication cart to reveal one pack of Montego (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 2 of 8 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 675868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hereford Nursing & Rehabilitation 231 Kingwood St Hereford, TX 79045 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 Blue 100's in the left drawer behind liquid items. Level of Harm - Minimal harm or potential for actual harm Interview with LVN B at 11:32 AM revealed that there was one smoker on four hall at that time. LVN B stated Resident #20's smoking materials were kept in the facility at the medication cart. LVN B showed the surveyor where Resident #20's cigarettes were in the medication cart which was the top right corner. LVN B indicated that there were only two smokers in the building. LVN B stated that a negative outcome would be Fire hazard. LVN B indicated that Resident #19 had a lighter and cigarettes in room. LVN B stated, I know they are not supposed to. LVN B revealed that the Smoking policy stated they were not supposed to have anything in their rooms, and they were either kept in the medication cart or the medication room because they are locked. Residents Affected - Some Interview with CNA F on 6/8/23 at 11:45 AM revealed one resident that smokes in five hall. Inquired which resident and identified Resident #13. CNA F stated that cigarettes were in the medication cart. CAN F stated Resident #13 keeps lighter and a negative outcome of the resident keeping the lighter would be a fire hazard. CNA F also stated that resident was allowed to have a lighter when resident was of sound mind. CNA F stated smoking policy revealed they were to be supervised while outside. Interview with LVN E on 6/8/23 at 11:48 AM revealed LVN E was not aware of Resident #13's lighter location and that resident has never had a lighter on him. LVN E stated a fire hazard as a possible negative outcome. LVN E indicated that lighters were not allowed in rooms. LVN E stated the smoking policy revealed, not without going back and looking at it. Interview on 6/8/23 at 1:49 PM with LVN B revealed new cigarettes in the med cart labeled Marlboro Red 100's with Resident #19's name in black marker in top right-hand corner. LVN B advised that cigarettes were brought back to the medication cart LVN B advised that CNA went into resident's room and returned them to the medication cart. Interview on 6/8/23 at 1:54 PM with DON. The DON advised there were no in-services on the smoking policy and training is completed upon initial hire date. DON advised the smoking policy is the residents are not allowed to go out without a staff member. DON indicated that smoking materials are kept in the medication cart. DON indicated that a negative outcome of residents keeping smoking materials in their room was would be confiscated; I don't know what you're asking. The DON responded with I don't know what you are asking, a lot of things can happen. Interview with the DON on 6/8/23 at 2:06 PM revealed that smoking assessments were completed upon admission and quarterly. Advised that RNs completed them upon admission and the ADON completed them quarterly. Interview with the ADON on 6/8/23 at 2:08 PM revealed that in-service for smoking was done upon hire. ADON advised that smoking policy stated smoking materials are in the medication carts separated from other items. The ADON also stated that there were three smokers in the building and a negative outcome of smoking materials being in resident's rooms would be a fire. Interview and record review with the DON, ADM, and ADON on 6/9/23 at 8:55 AM revealed that three policies were provided for smoking. One policy labeled Smoking Policy Resident/Family Copy (no date) identified residents were allowed to keep smoking paraphernalia in their room when supervised. DON indicated supervised meant they don't go by themselves, so they are supervised. The ADM indicated it meant that they know they have their smoking materials on them. The ADON walked into the room at 8:58 AM and indicated that the smoking assessment asked if they can be unsupervised, and verbiage is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 3 of 8 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 675868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hereford Nursing & Rehabilitation 231 Kingwood St Hereford, TX 79045 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 found on smoking assessment. ADM stated about smoking materials in resident's room, the care plan says that. ADON confirmed with head shake up and down. Interview with the ADM on 6/9/23 at 9:01 AM and inquired about record of policy in admission packet, policy provided to family, and facility policy with conflicting wording. Inquired which policy to go by since two were the same and Smoking Policy Resident/Family Copy (no date) stated smoking paraphernalia can be kept in room when supervised. The ADM stated, we will get that changed. Record review of policy named Items Not Allowed in Resident Room (no date), under Safety Hazards, last statement indicated Smoking or smoking materials-not allowed. Record review of policy named It is the policy of [the facility] to abide by the rules and regulations set forth by the Texas department of Aging and Disabilities, (no date), line 13 stated- Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession. Record review of Smoking Policy Resident/Family Copy (no date) revealed the following: Line 1, line (a) Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession with supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 4 of 8 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 675868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hereford Nursing & Rehabilitation 231 Kingwood St Hereford, TX 79045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly stored per food label. 2. The facility failed to practice proper hand sanitation while preparing food. Findings Included: Observation of shelved foods on 6/7/2023 at 10:00am revealed the following: 1. Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening. Observation on 6/7/23 During an observation on 6/7/23 at 10:30 AM, observed [NAME] A preparing puree food. [NAME] A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. Gloves were not worn, and no hand hygiene was practiced between these actions. During an interview on 6/8/2023 at 2:30pm with [NAME] A, DM, translated due to language barrier, stated that all kitchen staff are responsible for safe food preparation per their policy. [NAME] A stated that she would go to the Facility policy to see what the policy stated. [NAME] A stated that the negative outcome for not practicing hand hygiene would be cross contamination. Record review of in-service dated 1/9/23 at 1:30 PM, training contained hand washing and sanitation. Record review of policy titled Hand Washing, dated 2012, it stated that employees are too frequently perform hand washing. Record review of policy titled Handwashing: A Healthy Habit in the Kitchen, dated September 1, 2021, the policy stated : Clean: Wash Hands, Utensils, and Surfaces Often-Wash your hands often, especially during these key times when germs can spread: After touching garbage Record review of recommendations of the Food and Drug Administration (FDA), dated 1997, it states that the FDA has evaluated the labeling on foods that must be refrigerated to prevent outgrowth of pathogensFebruary 1997. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 5 of 8 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 675868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hereford Nursing & Rehabilitation 231 Kingwood St Hereford, TX 79045 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 Record review of FDA recommendations on Are You Storing Food Safely, dated 1/18/23, it stated Check storage directions on labels. Many items other than meats, vegetables, and dairy products need to be kept cold. If you've neglected to properly refrigerate something, it's usually best to throw it out. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 6 of 8 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 675868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hereford Nursing & Rehabilitation 231 Kingwood St Hereford, TX 79045 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 14 residents (Resident #1) reviewed for immunization records. The facility failed to ensure records regarding patient care, including bed rails, was accurate and complete. This deficient practice placed residents at risk for inaccurate records to ensure continuity of and appropriate care. Findings included: Record review of Resident #1's face sheet dated on 6/8/23 revealed a [AGE] year-old woman who was admitted into the facility on 3/26/23. Diagnoses included encephalopathy (disease that affects the brain causing altered mental status), hyperlipidemia (elevated lipids), unspecified psychosis, disorientation, cardiac arrhythmia, hypo-osmolality and hyponatremia (low plasma). Record review of Resident #1's MDS assessment dated [DATE] indicated a brief interview for mental status of 05 indicating severe cognitive impact. Record review of Resident #1's bed rail assessment dated [DATE] showed not completed by the admitting nurse. Record review of Resident #1's bed rail consent dated 3/6/23 showed not completed by the admitting nurse and signed by the resident representative. Record review of Resident #1's Influenza Informed Consent (no date) showed not completed but signed by the resident representative. Record review of Resident #1's Pneumococcal Informed Consent dated 3/6/23 showed not completed but signed by the admitting nurse and resident representative. Interview with the DON on 06/09/23 at 10:52 AM revealed that the charge nurse did bed rail assessments when a resident was admitted . The DON stated what information was on the Bed Rail assessment. DON indicated the size of rail, if there was one, and what side. The DON revealed LVN C was a charge nurse. DON looked at the form, confirmed it was LVN C's signature and it was not completed correctly. The DON stated a negative outcome could be with an uncompleted assessment, she could have a rail and not need one. Interview with LVN C on 06/09/23 at 11:04 AM revealed needing a bed rail assessment is the reason for needing it and the patient's ok if they want to use them or not. The reasons why it would help them LVN C identified the resident or resident representative could sign the consent. LVN C stated a negative outcome could be entrapment if they are caught in the bed rail. If something was to happen to them. LVN C confirmed that LVN C's signature was on Resident #1's Bed Rail Assessment form dated 3/6/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 7 of 8 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 675868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hereford Nursing & Rehabilitation 231 Kingwood St Hereford, TX 79045 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview and record review with the DON on 6/9/23 at 11:08 AM revealed the charge nurse completed bed rail assessments upon admission. The DON stated the type of rail that had been determined and the resident signature or the person giving consent was needed. The DON revealed that a negative outcome for an incomplete form if signed by both nurse and Representative/Resident meant it was completed without something being fully assessed. The DON confirmed the consent for Resident #1's bed rails was not completed and confirmed the signature on the form was LVN C's. Interview and record review with LVN C on 6/9/23 at 2:25 PM revealed Resident #1's influenza and pneumococcal consents were not completed. LVN C revealed obtaining the signatures before completing the forms. LVN C confirmed completed admission paperwork for Resident #1. LVN C stated LVN C called the clinic but it was close to end of shift. Told them (employees) if they call this is what we are looking for. I told them I just needed a record for chart. I know I messed up. It's my fault. LVN C confirmed did not get a yes or no on the Influenza Consent and that the Pneumococcal Consent was not filled out correctly with her signature at the bottom. LVN C identified a negative outcome of being unable to tell if resident has had the vaccine or needs the vaccine since forms were not completed. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 indicates that documentation is the recording of all information in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 Under heading Goal-Line (1) states the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 under heading Procedure Line (3) Place all required and appropriately signed forms in the clinical record. Items such as copies of .consent for treatment, consents for specific procedures . will be placed behind labeled dividers inside the clinical record. Line (6) document completed assessments in a timely manner and per policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675868 If continuation sheet Page 8 of 8