Health inspection·May 6, 2025

F 0552 Depakote for Resident #65. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/06/25 at 05:45PM with the ADON, he could not find a consent for Resident #65 Depakote. He stated all staff had been trained on obtaining consents. He stated the nurses were responsible for obtaining consent for medications when they receive the order. He stated the potential negative outcome could be giving unnecessary medications to residents or giving medications against the residents or family wishes. Residents Affected - Few During an interview on 05/06/25 at 6:00PM, the ADM stated currently the ADON, DON or the charge nurses were responsible for obtaining a signed consent form for psychotropic medications from the resident or their responsible party on the same day it was received from the physician. The ADM stated the consent should have been obtained prior to the residents being given psychotropic medications. The ADM stated he believed the reason the consent form was missing was because of a human error. The ADM stated a potential negative outcome to the residents was the resident was receiving a medication without consent. Policy It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Procedure: On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All effort will be made by the Licensed Nurses (LN) to obtain as much history regarding these medications, including prior informed consents, from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record. Upon change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to the initiation of the new medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 2 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all residents had the right to formulate advance directives for 3 of 30 residents (Residents #12, #23, and #45) reviewed for advanced directives. The facility failed to ensure Residents #12, #23, and #45 who were listed as DNR (Do Not Resuscitate), had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that did not have missed required information on the OOH-DNR. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #12 Record review of Resident #12's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and had diagnosis which included Dementia (irreversible that causes mental deterioration), Traumatic Brain Injury (brain dysfunction caused by an outside source), Asthma (inflamed, narrow airways that swell and make it difficult to breathe, Acute Cystitis (bladder inflammation), and Hypertension (the force of blood against the artery walls is too high). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #12's physician order summary dated 05/06/25 reflected the following order: DNR-Do Not Resuscitate dated 03/10/23. Record review of Resident #12's care plan, dated 10/08/23, reflected care plan for DNR. Record review of Resident #12's OOH-DNR form dated 04/26/21 reflected there was no signature at the bottom of the DNR for the notary utilized for the DNR. Resident #23 Record review of Resident #23's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and had diagnosis which included Parkinson's Disease (disorder of the central nervous system), Alzheimer's Disease (destroys memory and other important mental functions), Overactive Bladder (sudden need to urinate), bipolar disorder (episodes of mood swings). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #23's physician order summary dated 05/06/25 reflected the following order: DNR-Do Not Resuscitate dated 11/23/22. Record review of Resident #23's care plan, dated 11/04/22, reflected care plan for DNR. Record review of Resident #23's OOH-DNR form dated 01/09/20 reflected there was no printed doctor's name and no date for the doctor's signature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 3 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0578 Resident #45 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #45's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and had diagnosis which included Post Traumatic Stress Disorder (difficulty recovering after experiencing a terrifying event), Dementia (irreversible that causes mental deterioration), Alzheimer's Disease (destroys memory and other important mental functions), and Major Depression Disorder (persistent sadness). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Residents Affected - Few Record review of Resident #45's physician order summary dated 05/06/25 reflected the following order: DNR-Do Not Resuscitate dated 01/23/25. Record review of Resident #45's care plan, dated 07/10/23, reflected care plan for DNR. Record review of Resident #45's OOH-DNR form dated 07/17/24 reflected there was no date that accompanied the doctor's signature signatures. During an interview on 05/06/25 at 5:25pm with the SW, she stated OOH DNR was not valid if it's not filled out correctly. She stated she was responsible for ensuring OOH-DNRs were completed correctly. She stated there was no system for monitoring OOH-DNRs for accuracy. She stated the reason the DNR's were not complete was human error. She stated she has been trained on OOH-DNRs. The SW stated the potential negative outcome for residents if a DNR was not completed correctly was the Resident may not have their final wishes honored. During an interview on 05/06/25 at 5:40PM with the ADM, he stated the OOH DNR was not valid if not filled out correctly. He stated the SW was responsible for making sure the OOH DNR was completed accurately. He stated they did not have a system in place to monitor OOH DNR for accuracy. He stated the SW should be reviewing the OOH DNRs for accuracy. He stated he did not know why the information was missing. He stated the potential negative outcome was the Resident's end of life wishes may not be honored. He stated he was trained on how to complete OOH DNR and his expectation were for the OOH DNRs to be filled out completely and be correct. Record review of the Social Services Policies and Procedures Advanced Directives (Revised December 2023) reflected the following: Policy Resident's choice about advance directives will be recognized and respected; the facility will inform and provide written information to all adult resident concerning their right to accept or refuse medical treatment, and, at the resident's option, formulate am advance directive. It is the policy of this facility to implement the resident's decisions and directives that are in compliant with State and/or Federal Law and policies of this facility. Procedure: Prior to, upon, or immediately after admission a facility staff member shall provide written information to the resident or their representative regarding their right to accept or refuse medical treatment and the right to formulate an advanced directive. Facility staff will review the advanced (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 4 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0578 directive to ensure it honors the wishes of the resident or their representative, and ensure the document is signed and dated by the resident or its representative. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 5 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure all residents had the right to personal privacy which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 3 of 3 residents (Resident #32, Resident #35, and Resident #90) reviewed for privacy. Residents Affected - Few 1. LVN A failed to close the door, the curtain, the blinds, or provide a sheet or towel for coverage during wound care for Resident #32. 2. CNA D and CNA E did not close the door or close the curtain all of the way during incontinent care for Resident #35. 3. CNA F had provided peri care for Resident #90 and failed to close the blinds. This failure could place residents at risk of being exposed and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem. Finding included: Resident #32 Record review of Resident #32s face sheet undated revealed an [AGE] year-old female with an admission date of 11/08/2023 with the following diagnoses: Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls), pressure ulcer of right buttock (stage 3), pressure ulcer of sacral region (stage 3), dysphagia (difficulty swallowing), cognitive communication deficit, anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), type 2 diabetes, vitamin deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acid reflux, muscle weakness, osteoporosis (a condition in which bones become weak and brittle). Record review of Resident #32's Annual MDS dated [DATE] revealed a BIMS score blank and incomplete. During an observation of wound care on 05/05/2025 at 2:33 PM, LVN A failed to provide full privacy for Resident #32 during wound care to the coccyx. LVN A failed to close the door, the curtain, the blinds, or provide a sheet or towel for coverage during wound care. Resident #32 was sitting in her wheelchair and LVN A had Resident #32 stand up and bend over while holding onto the bed. LVN A pulled Resident #32's pants down and removed the brief. LVN A removed the dirty bandage. LVN A put calcium alginate and bandage on the wound. LVN A placed on new brief on Resident #32 and pulled up Resident #32's pants. Resident #32's room was in front of a busy parking lot. During an interview on 05/06/2025 at 3:25 PM, LVN A stated that the policy stated that full privacy should be provided at all times during care. LVN A stated that she did not provide privacy leaving the door open, the blinds open, did not shut the curtain all of the way, leaving it halfway open, and did not provide a cover. LVN A stated that she was just nervous. LVN A stated that it could have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 6 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0583 Level of Harm - Minimal harm or potential for actual harm caused the resident to be embarrassed and cause other residents to ridicule due to being exposed. LVN A stated that it could make the resident not trust staff and feel as though they are not being respected and valued. LVN A stated that she has had training in dignity through in-services and Relias, every few weeks. LVN A stated that the DON and ADON are responsible for overseeing the training. Residents Affected - Few Resident #35: Record review of Resident #35s face sheet dated 05/06/2025 revealed a [AGE] year-old female with an original admission date of 0/9/03/2020 and an initial admission date of 10/08/2019 with the following diagnoses: Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, need for assistance for personal care, dementia, dysphagia (difficulty swallowing), depression, diarrhea, chronic kidney disease, anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), atherosclerotic heart disease, attention and concentration deficit, osteoporosis, unsteadiness on feet, gastrointestinal hemorrhage. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 2 meaning that Resident #2 had severe cognitive impairment. During an observation of incontinent care on 05/05/2025 at 10:34 AM, CNA D and CNA E failed to provide full privacy during providing incontinent care for Resident #35. CNA D and CNA E did not close the door or close the curtain all of the way during incontinent care. CNA D and CNA E did not provide any form of coverage for the resident during incontinent care, leaving Resident #35 completely exposed during incontinent care. During an interview on 05/06/2025 at 1:51 PM, CNA D stated that the policy for providing privacy stated that staff should provide privacy by closing the blinds, curtains are closed, the door is closed, and providing a towel or sheet to cover the resident. CNA E stated that she could have done better at providing privacy for Resident #35. CNA E stated that someone could have come in during incontinent care and the resident would have been exposed. CNA E stated that it could have embarrassed the resident or made them feel uncomfortable. CNA E stated that she had been trained in privacy and dignity by in-services, monthly. CNA D stated that the DON and ADON are responsible for overseeing the training. During an interview on 05/06/2025 at 3:47 PM, CNA E stated that the policy for dignity and providing privacy during care to close the door and pull the curtain and blinds. CNA E stated that she had training in dignity through in-service, every few weeks. CNA E stated that she did not provide full privacy during incontinent care. CNA E stated that she had not thought about it. CNA E stated that the resident may feel embarrassed if someone were to see them undressed. Resident #90: Record review of Resident #90s face sheet undated revealed a [AGE] year-old female with an admission date of 03/08/2025 with the following diagnoses: constipation, urinary tract infection, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), severe sepsis (a life-threatening complication of an infection), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), acute diastolic heart failure, hemoperitoneum (a life-threatening condition that occurs when blood accumulates in the heart's pericardial sac), acute kidney failure with tubular necrosis, neuromuscular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 7 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dysfunction of bladder, dysphagia (difficulty swallowing), need for assistance with personal care, anemia (condition in which the blood does not have enough healthy red blood cells and hemoglobin), pneumonia, overactive bladder. Record review of Resident #90's quarterly MDS dated [DATE] revealed a BIMS score listed as 5 meaning severe cognitive impairment. During an observation of incontinent care on 05/05/2025 at 11:22 AM, CNA F had provided peri care for Resident #90 and failed to close the blinds. The blinds were left open during the entire peri care process and Resident #90 was exposed due to the parking lot being outside the window. CNA F did not cover Resident #90 during the peri care process. Observed cars pulling in and out of the parking lot while CNA F was providing peri care for Resident #90. CNA F did not provide any coverage during incontinent care. During an interview on 05/06/2025 at 2:29 PM, CNA F stated that the policy for providing privacy during peri care stated that she should shut the door, curtains, windows, and provide full privacy. CNA F stated that she should have covered the resident. CNA F stated that the policy stated that full privacy should be provided for all residents. CNA F stated that she did not provide full privacy for Resident #90. CNA F stated that it would be a dignity issue for not respecting Resident #90's privacy and keeping covered. CNA F stated that it could make the resident feel embarrassed. CNA F stated that she had training for dignity and privacy through Relias and in-services, every 3 weeks. CNA F stated that HR is responsible for overseeing the training. During an interview on 05/06/2025 at 2:00 PM, The Administrator stated that the policy stated that privacy should be provided and per policy. The Administrator stated that it is the responsibility of the nurse managing team and DON to oversee the training. The Administrator stated that training in privacy and dignity is provided on Relias. The Administrator stated that his expectations were for staff to follow policy. The Administrator stated that the negative potential outcome for not providing privacy to a resident during care could make them feel embarrassed. During an interview on 05/06/2025 at 4:23 PM, The DON stated that her expectations for staff would be to follow policy for privacy and dignity. The DON stated that she expects staff to provide privacy during care. The DON stated that staff had been trained in dignity and privacy in Relias which is self-paced and due every year. The DON stated that the negative potential outcome of not providing the resident privacy is that they could become embarrassed. Record review of the facility Dignity & Respect policy dated revised October 2015: Policy Statement: It is the policy of this facility that all residents be treated with kindness, dignity, and respect. Policy Interpretation and Implementation 4. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. 5. Privacy of a Resident's body shall be maintained during toileting, bathing and other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 8 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0583 activities of personal hygiene, except when staff assistance is needed for the Resident's safety. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 9 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 30 confidential residents. The facility failed to ensure 12 of 30 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 05/05/2025 at 2:00pm, 12 confidential residents, stated they did not have access to the Grievance form following the facility's remodel. The residents did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The 12 residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 05/05/2025 at 4:15pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 05/06/2025 at 5:01pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was available for the Residents all the nurses' stations and the SW office. The ADM stated when residents present a Grievance issue to staff, the staff complete a Grievance form for the resident. The ADM stated there was no procedure for Residents to submit grievances anonymously. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated he assigns the grievance to the appropriate department, that department addresses the grievance, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the original Grievance form. The ADM stated completed Grievances were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff at morning meetings. The ADM stated the Interdisciplinary Team was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council. Record Review of the Grievance Policy: Policy: The facility will establish a grievance process that allows residents a way to execute their concerns or grievances to the facility without fear of discrimination or reprisal. The information on how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 10 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0585 to file a grievance will be available to the residents and make prompt efforts to resolve the grievance. Level of Harm - Minimal harm or potential for actual harm Procedure: Information is made available to the resident and posted in designated locations throughout the facility. Residents Affected - Some The resident or their representative have the right to file a grievance orally, in writing, or anonymously. The resident or their representative have the right to receive a written decision regarding their grievance. The decision regarding the grievance will be presented to the resident or their representative within three working days. The full grievances and the grievance log will be maintained by the facility for three years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 11 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, Interviews, and Record Review the facility failed to ensure residents were free from involuntary seclusion for 5 of 32 (Residents #8, #24, #59, #89, and #96) residents reviewed for involuntary seclusion. Residents Affected - Some The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secured/locked unit for Residents #8, #24, #59, #89, and #96. There was no update to the Care Plan for Resident #96 for placement in the secure/locked unit. This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm. Findings included: Resident #8 Record review of the face sheet, dated 05/05/2025, revealed Resident #8 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Alzheimer's disease (progressive, irreversible brain disorder), Chronic obstructive pulmonary disease (COPD (ongoing lung condition caused by damage to the lungs), cognitive communication deficit (difficulties in communication from impairments in cognitive processes), and need for assistance with personal care. Record review of Resident #8's MDS assessment, dated 08/10/2024, revealed Resident #8 had a BIMS score of 04, which indicated severely impaired cognition. Record review of the current care plan for Resident #8, date initiated 08/9/2023 and a revision date of 08/28/2023, revealed a focus area that stated, (Resident) is at risk for impaired cognitive function/Alzheimer or impaired thought processes r/t diagnosis of dementia alert, with a goal that stated, Will maintain current level of cognitive function through the review date., and the intervention and tasks that stated, Needs supervision/assistance with all decision making. family involved in decisions An additional focus area stated, (Resident) is an elopement risk/wanderer r/t history of attempts to leave facility unattended, and impaired safety awareness. Resident resides on a locked unit for optimal safety., with a goal that stated, Safety will be maintained through the review date. and interventions that stated, Assess for fall risk. Date Initiated: 07/14/2024, Created on: 07/14/2024, Document wandering behavior and attempted diversional interventions. Date Initiated: 07/14/2024 Created on: 07/14/2024, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. An interview was attempted with Resident #8 on 05/04/2025 at 3:30 PM and Resident #8 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. During an observation on 05/05/2025 at 5:20 PM Resident #8 was observed walking to the door of the secure/locked unit to see if someone was there for her, and Resident #8 was unable to open the door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 12 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0603 Resident # 24 Level of Harm - Minimal harm or potential for actual harm Record review of the face sheet, dated 05/05/2025, revealed Resident #24 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety' (decline in cognitive abilities), Atrial fibrillation (AFib) (irregular and often very rapid heart rhythm), Anxiety Disorder (excessive worry about everyday issues and situations), and Major Depressive Disorder (mood disorder that causes persistent feelings of sadness and loss of interest). Residents Affected - Some Record review of Resident #24's MDS assessment, dated 10/21/2024, revealed Resident #24 had a BIMS score of 00, which indicated severely impaired cognition. Record review of the current care plan for Resident #24, date initiated 09/22/2017 and a revision date of 09/14/2023, revealed a focus area that stated, (Resident) is an elopement risk/wanderer r/t Dementia. Resident is in a secure unit for safety and optimal well being d/t cognition., with a goal that stated, Safety will be maintained through the review date., and the intervention and tasks that stated, Assess for fall risk. Date Initiated: 10/05/2017 Created on: 10/05/2017; Document wandering behavior and attempted diversional interventions. Date Initiated: 10/05/2017 Created on: 10/05/2017; Monitor for fatigue and weight loss Date Initiated: 10/05/2017 Created on: 10/05/2017; RESIDENT REQUIRES A SECURED UNIT RELATED TO DX: UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE. Date Initiated: 10/05/2017 Created on: 10/05/2017. An interview was attempted with Resident #24 on 05/04/2025 at 4:01 PM and Resident #24 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. Resident #59 Record review of the face sheet, dated 05/05/2025, revealed Resident #59 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety' (decline in cognitive abilities), Generalized Anxiety Disorder (excessive worry about everyday issues and situations), Alzheimer's disease (progressive, irreversible brain disorder), Cognitive communication deficit, and Intermittent Explosive Disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts). Record review of Resident #59's MDS assessment, dated 04/08/2025, revealed Resident #59 had a BIMS score of 02, which indicated severely impaired cognition. Record review of the current care plan for Resident #59, date initiated 05/05/2025 revealed a focus area that stated, Elopement risk/wanderer r/t Impaired safety awareness, Resident wanders aimlessly. Resident is in a secure unit for safety and optimal well being, with a goal that stated, Safety will be maintained through the review date. Will not leave facility unattended through the review, and the intervention and tasks that stated, Document wandering behavior and attempted diversional interventions. Date Initiated: 05/05/2025 Created on: 05/05/2025; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 05/05/2025 Created on: 05/05/2025. An interview was attempted with Resident #59 on 05/05/2025 at 10;30 AM and Resident #59 was unable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 13 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. Resident #89 Record review of the face sheet, dated 05/05/2025, revealed Resident #89 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included the following: Vascular dementia (decreased blood flow to areas of the brain, leading to damage to brain tissue and a decline in mental functions), Cognitive communication deficit, depression, and heart failure. Record review of Resident #89's MDS assessment, dated 02/27/2025, revealed Resident #89 had a BIMS score of 08, which indicated moderately impaired cognition. Record review of the current care plan for Resident #89, date initiated 02/25/2025 and a revision date of 05/05/2025, revealed a focus area that stated, Elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness. (Resident) resides on a locked unit for optimal safety r/t cognition, with a goal that stated, Will not leave facility unattended through the review date., and the intervention and tasks that stated, Document wandering behavior and attempted diversional interventions. Date Initiated: 02/25/2025 Created on: 05/05/2025; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 2/25/2025 Created on: 05/05/2025; Monitor for fatigue and weight loss. Date Initiated: 02/25/2025 Created on: 05/05/2025; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: 02/25/2025 Created on: 5/05/2025. During an interview with Resident #89 on 05/05/2025 at 10:10 AM Resident #89 was unable to articulate where he was currently residing. Resident #89 stated he was working a shift at the EMS as a paramedic. Resident #89 was unable to state what the code to the door of the secure/locked unit was. The resident was confused by the question and stated he did not know there was a code for the door. Resident #96 Record review of the face sheet, dated 05/05/2025, revealed Resident #96 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Encephalopathy (brain disease, damage, or malfunction), Schizoaffective disorder (mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder), Generalized Anxiety Disorder (excessive worry about everyday issues and situations), and Dementia in other diseases classified elsewhere, moderate, with mood disturbance (memory loss that deteriorates over time). Record review of Resident #96's MDS assessment, dated 04/07/2025, revealed Resident #96 had a BIMS score of 02, which indicated severely impaired cognition. Record review of the current care plan for Resident #96, date initiated 04/15/2025 and a revision date of 04/27/2025, revealed a focus area that stated, (Resident #96) is at risk for impaired cognitive function/dementia or impaired thought processes, with a goal that stated, Will be able to communicate basic needs on a daily basis through the review date., and the intervention and tasks that stated, Administer medications as ordered. Communicate with family/caregivers regarding resident's capabilities and needs. Discuss concerns about confusion, disease process and alternative placement with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 14 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0603 family/caregivers. Level of Harm - Minimal harm or potential for actual harm Record review of Social Services Assessment/Evaluation for Resident #96, dated 04/11/2025 revealed the following: Strong desire to return home, requires Secured Unit. Residents Affected - Some An interview was attempted with Resident #96 on 05/05/2025 at 5:20 PM and Resident #96 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. An attempted telephone interview was made on 05/6/2026 at 12:35 PM to the physician for Resident #8, #24, #59, #89, and #96 with no response. During an interview with on 05/06/2025 at 2:20 PM the DON stated it was not the facility's policy to obtain a physician's order prior to placing a resident in a secured/locked unit. The DON stated she was not familiar with the State Operations Manual as it pertained to secure/locked units. The DON stated the Residents #8, #24, #59, #89, and #96 did not have the access code to enter or exit the secure/locked unit (Oak). The DON stated the Residents #8, #24, #59, #89, and #96 were on the secure/locked unit for their safety. The DON stated prior to placing a resident on the secure/locked unit, the resident was assessed to determine if they met the criteria for the unit, which included an assessment for elopement risk and monitoring for behaviors after admission and overall adjustment. The DON stated Residents #8, #24, #59, #89, and #96 were fully assessed and met the criteria for the secure/locked unit. The DON stated staff received orientation upon hire for the secure/locked unit. The DON stated the IDT team was responsible for ensuring documentation was completed for residents placed on the secure/locked unit. The DON stated she did not feel a resident being placed in a secure/locked unit was the same as a restraint. The DON stated if a resident was placed on a secure/locked unit without an adequate assessment or proper documentation, the resident's overall adjustment could have been negatively impacted. During an interview on 05/06/2025 at 2:45 PM the ADM stated the facility's policy did not state a physician's order was necessary for residents to be placed in a secure/locked unit. The ADM stated he had not seen this information in the State Operations Manual. The ADM stated the Residents #8, #24, #59, #89, and #96 did not have access to the door code to enter or exit the secure/locked unit (Oak). The ADM stated Residents #8, #24, #59, #89, and #96 were assessed for elopement risk. The ADM stated visual observations were made of the residents as well as assessing the residents' BIMS prior to placement on the secure/locked unit. The ADM stated the IDT team was responsible for ensuring residents met the criteria for placement on the secure/locked unit. The ADM stated the nursing staff, floor staff, and nurse management staff were responsible for ensuring all documentation and assessments were completed prior to placing a resident on a secure/locked unit. The ADM stated he did not feel there was a negative impact to a resident if they were placed on a secure/locked unit without a physician's order as no resident was placed on the secure/locked unit without an elopement assessment. Record Review of the facility's policy titled Restraints, dated 06/2017 revealed the following: Policy: It is the policy of this facility to refuse to restrain residents for any cause. PROCEDURE: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 15 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0603 Level of Harm - Minimal harm or potential for actual harm Should a resident have cause for need of restraint, the physician will be notified immediately, and Texas state regulations will be followed. As soon as possible, residents with need for restraints will be transferred to an appropriate facility. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 16 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 32 residents (Resident #96) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #96, specific to Resident #96 being placed in a secured/locked unit. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #96 Record review of the face sheet, dated 05/05/2025, revealed Resident #96 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Encephalopathy (brain disease, damage, or malfunction), Schizoaffective disorder (mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder), Generalized Anxiety Disorder (excessive worry about everyday issues and situations), and Dementia in other diseases classified elsewhere, moderate, with mood disturbance (memory loss that deteriorates over time). Record review of Resident #96's admission MDS assessment, dated 04/07/2025, revealed Resident #96 had a BIMS score of 02, which indicated severely impaired cognition. Record review of the current care plan for Resident #96, date initiated 04/15/2025 and a revision date of 04/27/2025, revealed a focus area that stated, (Resident) is at risk for impaired cognitive function/dementia or impaired thought processes, with a goal that stated, Will be able to communicate basic needs on a daily basis through the review date., and the intervention and tasks that stated, Administer medications as ordered. Communicate with family/caregivers regarding resident's capabilities and needs. Discuss concerns about confusion, disease process and alternative placement with family/caregivers. Record review of Social Services Assessment/Evaluation for Resident #96, dated 04/11/2025 revealed the following: Strong desire to return home, requires Secured Unit. Record review of nursing progress note for Resident #96, dated 04/17/2025 revealed the following: patient is having behaviors and was moved to the locked unit due to being a high elopement risk.' Record review of Resident #96's physician's order revealed no order to place Resident #96 in a secure/locked unit. During an observation on 05/05/2025 at 5:30 PM Resident #96 was observed in the dining room of the secure/locked unit during dinner service. Resident #96 was observed eating dinner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 17 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/06/2025 at 02:00 PM, MDS B stated MDS nurses were responsible for completing and updating care plans for residents, and the IDT team was responsible for ensuring updates were communicated for each resident. MDS B stated care plans were updated frequently for any acute changes, and changes were updated immediately, as seen, or as reported. MDS B stated the MDS nurses trained staff on resident's care plans. MDS B stated she was unaware Resident #96's care plan did not reflect that Resident #96's was in a secured/locked unit. MDS B stated when a resident was on a secured/locked unit, it was usually indicated on a resident's care plan. MDS B verified Resident #96's care plan did not reflect that Resident #96 was on a secured/locked unit. MDS B stated a resident's current condition was discussed daily during morning meetings with the IDT team. MDS B stated any changes to a resident's current condition should have been updated on the resident's care plan as soon as the change was known. MDS B stated care plans were normally updated timely and since changes were also communicated verbally to staff, she did not feel the care plan, not indicating that Resident #96 was in a secured/locked unit, negatively impacted the resident During an interview on 05/06/2025 at 2:25 PM, the DON stated she was unsure of the facility's policy regarding updating a care plan. The DON stated care plans were updated by the IDT team, and all staff were responsible for ensuring they were completed and accurate. The DON stated she was not aware Resident #96's care plan should reflect that Resident #96 was placed in a secured/locked unit. The DON stated staff were usually trained by the MDS nurses and the DON on residents' care plans. The DON stated care plans were completed upon admission and reviewed quarterly by the IDT team. The DON stated a resident's current condition and any changes to condition were discussed daily in morning meetings held by the IDT team, and any changes necessary were to be made to the care plans as soon as the change was known. The DON stated if a resident's care plan was not completed or accurate, information about the resident could be missed. During an interview on 05/06/2025 at 2:50 PM, the ADM stated care plans were usually updated by the MDS nurses after the IDT team met to discuss the resident's needs. The ADM stated all of the IDT team was responsible for ensuring the care plans were updated and accurate. The ADM stated the IDT team was responsible for monitoring the accuracy of the care plan, and all staff were responsible for reporting any changes and/or updates that were needed. The ADM stated a resident's current condition, and any changes of condition were discussed during morning meetings held daily by the IDT team. The ADM stated the expectation was for the care plan to be accurate, and it should have been updated as soon as a change of condition was known. The ADM stated he was not aware Resident #96's care plan should have been specific to include Resident #96 was on a secured/locked unit. The ADM stated, if a care plan did not reflect that a resident was on a secured/locked unit, he did not feel this would negatively impact the resident as he stated all care was not solely based on a resident's care plan. Record review of the facility's policy titled, Comprehensive Resident Centered Care Plan dated November 2016 with a review date of January 2022 and December 2023, reflected the following: Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 18 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 - Few 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. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 4 medication carts (Sage medication cart and Oak medication cart), reviewed for medication storage. The medication cart assigned to Sage and Oak contained loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions. The findings included: On 05/05/2025 at 01:30 PM, an observation of the medication cart for Sage was conducted with LVN C. One loose pill (white round with 196 on one side) was found in the second drawer of the medication cart. LVN C identified the loose pill as clopidogrel (Plavix) 75 mg using her cell phone. LVN C destroyed the loose pill by placing it in the sharps container on the medication cart. On 05/05/2025 at 04:06 PM, an observation of the medication cart for Oak was conducted with LVN B. One loose pill (1/2 white oval) was found in the second drawer of the medication cart. LVN B was not able to identify the loose pill and destroyed the loose pill by placing it in the sharps container on the medication cart. During an interview on 05/06/2025 at 01:18 PM, LVN C stated there should be no loose pills on the medication cart. She stated she was not sure why the medication cart contained a loose pill. She stated she thought it was a small piece of paper. She stated it was the nurse's responsibility to assure medications were properly stored on the medication cart. She stated medication cart was to be checked after each medication pass. She stated she has had training on monitoring the medication for loose pills and expired medications. She stated the potential negative outcome could be giving the wrong medication. During an interview on 05/06/2025 at 01:31 PM, the DON stated there should be no loose pills in the medication carts. She stated it was the nurse's responsibility to check carts for loose pill and expired medications. She stated the DON, ADON and Pharmacy Consultants does random cart checks. She stated all staff have been trained. She stated the potential negative outcome could be the nurses accidently picking the medication up and giving to the wrong resident. During an interview on 05/06/2025 at 03:22 PM, LVN B stated there should not be loose pills in the medication cart. She stated the nurses were responsible for checking medication carts a couple times a week. She stated she was not aware the loose pill was in the medication cart. She stated she had been trained to check the medication cart for loose pills. She stated the potential negative outcome was there was no way to identify the medication and resident could get the wrong medication. During an interview on 05/06/2025 at 03:30 PM, the ADM stated there should not be loose pills in the medication cart. He stated nursing was responsible for checking medication carts. He stated all staff had been trained. He stated he was not aware of loose pills in medication cart until this morning. He stated the potential negative outcome could be the residents not getting medications as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 19 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 ordered. Level of Harm - Minimal harm or potential for actual harm Record review of the facility-provided policy titled, Medication Access and Storage, revised May 2007, revealed: Residents Affected - Few Policy - It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Procedure: 1. The Provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 20 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. Residents Affected - Few The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (05/05/2025 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: The following confidential responses were provided during the initial pool interview screening process on 05/04/2025: A resident stated, The food is always cold. A second resident stated the food was cold and he does not eat it most of the time. A third resident stated, Meals are always cold. Two of those three residents stated they ate in their rooms, and one stated they ate in the dining room. Record review of the Resident Council Minutes dated 11/12/2024 revealed resident comments related to the food served in the facility. It was documented, food complaint. The corresponding grievance form completed for the food complaint in resident council listed the complaint as cold food. During an observation on 05/04/2025 at 1:10 PM of the dining service in Oak (secured unit) revealed the following: 16 residents were served in the dining room area by 2 nursing staff. The nursing staff were observed checking each food tray and food order for accuracy before serving the tray to the resident. Each nursing staff was observed setting up food plates and preparing utensils for each resident. The food service ended at 1:30 PM. On 05/05/2025 at 10:00 AM the Dietary Manager was informed of a request for a test tray for the meal served at 12:00 PM (lunch) and that the test tray was to be provided after the last tray was served on the secured unit. A test tray was requested for the regular diet, mechanical soft diet, and pureed diet. During a confidential group interview on 05/05/2025, 10 of 12 residents complained of receiving cold food on a daily basis. The residents stated they ate in the dining rooms as well as in their rooms. During an observation on 05/05/2025 at 12:23 PM of the dining service in Oak (secured unit) revealed the following: 17 residents were served in the dining room area by 3 nursing staff. The nursing staff were observed checking each food tray and food order for accuracy before serving the tray to the resident. Each nursing staff was observed setting up food plates and preparing utensils for each resident. The food service ended at 12:40 PM. On 05/05/2025 at 12:45 PM the test trays arrived at the conference room and sampling began at 12:46 PM with the following results: Regular meal plate - Regular Texture: Meatloaf with gravy, mashed potatoes, and greens were all cold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 21 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0804 Regular Meal - Mechanical Soft Texture: Meatloaf with gravy, mashed potatoes, and greens were all cold. Level of Harm - Minimal harm or potential for actual harm Regular Meal - Puree Texture: Meatloaf with gravy, mashed potatoes, and greens were all lukewarm. Residents Affected - Few During an interview on 05/06/2025 at 1:15 PM, the DM stated it was the facility's policy to serve food at an appetizing temperature to each resident. The DM stated she was not aware of any recent complaints of the food being cold. The DM stated the dietary staff were responsible for transporting food trays to each unit, and the nursing staff on those units were responsible for distributing trays to residents. She stated she was not sure if there was a policy or procedure for timeframes of how soon trays should be distributed after they were taken to the units. The DM stated food was always warm when it left the kitchen, but she was aware situations may arise that could cause the nursing staff to be pulled away from distributing food trays if residents required immediate attention from the nursing staff. The DM stated there was not a current system in place for dietary staff to assist in distributing food trays to residents as this was a task only completed by the nursing staff. The DM stated food trays were transported on carts that were not heated. The DM stated food was served on warmed plates with insulated clam shells to ensure food stayed warm. The DM stated she was not aware food service took approximately 20 minutes on the secured unit. The DM stated the clam shells and warmed plates may have not kept food warm for 20 minutes. The DM stated all staff were responsible for ensuring food was served at adequate temperatures. The DM stated the nursing staff had thermometers available on each unit to ensure food was served at proper temperatures, and they should have checked the temperatures prior to serving, if food was not served right away. The DM stated all staff were trained upon hire regarding serving food at adequate temperatures, and they also received in-service trainings. The DM stated it was her expectation that food was reheated prior to serving if it was not at an adequate temperature. The DM stated if food was not served at appetizing temperatures residents may not want to eat it. The DM stated food not served at proper temperatures could also cause illness to the residents. During an interview on 05/06/2025 at 2:20 PM the DON stated she was not aware of the facility's policy regarding food service temperatures. The DON stated food should have always been served at adequate temperatures. The DON stated it was all staff's responsibility to ensure food was served to residents at safe temperatures. The DON stated the dietary staff transported food trays to each unit and the nursing staff distributed each meal tray to the residents after checking the food for accuracy, according to the resident's dietary order. The DON stated the nursing staff had thermometers on each unit to check food temperatures. The DON stated she was unsure what training staff received regarding food service temperatures, but she stated each staff should have received training when they were hired. The DON stated if food was not served at an appropriate temperature to a resident, the resident may not eat it which could place a resident at risk of weight loss. The DON stated if food was served under the proper food service temperature, the resident could have been at risk of getting sick. During an interview on 05/06/2025 at 2:46 PM the ADM stated he was not sure what the facility's policy was regarding food service temperatures. The ADM stated food should always be served to residents at an adequate temperature. The ADM stated he was not aware the food service in the secured unit took approximately 20 minutes to serve every resident. The ADM stated it was every staff's responsibility to ensure food was served at adequate temperatures. The ADM stated the nursing staff served food trays to each resident after the dietary staff transported the food carts to each unit. The ADM stated the nursing staff had thermometers on each unit and were responsible for checking food temperatures, as well as the dietary staff. The ADM stated it was his expectation that food was served at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 22 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 0804 Level of Harm - Minimal harm or potential for actual harm safe temperatures. The ADM stated all staff received training upon hire regarding food service temperatures as well as regular in-service trainings. The ADM stated if food was served outside of the proper temperatures, a resident may not want to eat it which could have placed a resident at risk of weight loss. Record review of the facility's undated policy titled Food Flavor, Appearance and revealed the following: Residents Affected - Few POLICY: It is the policy of this facility to serve food prepared by methods that conserve nutritive value and enhance flavor and appearance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 23 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 observations, interviews, 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. The facility failed to properly store, label. and date foods stored in the refrigerator and freezer. The facility failed to properly store, label, and date perishable food items stored in the dry storage. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations and interviews were made on 05/04/2025 beginning at 10:15 AM during the initial observation of the kitchen: Observation on 05/04/2025 at 10:15 AM of the dry storage, in the kitchen, revealed two 20 ounce bottles of Welch's grape jelly. The two bottles were observed to be opened and half-filled. According to the manufacturer's label, the bottles should have been refrigerated after opening. One of the two bottles of jelly did not contain a date to indicate when the bottle had been received by the facility. During an interview on 05/04/2025 at 10:20 AM the DM stated she was unaware the bottles of jelly indicated they should have been refrigerated after opening. The DM stated the two bottles would be discarded and she planned to educate the dietary staff regarding the manufacturer's label instructions. Observation on 05/04/2025 at 10:43 AM of the walk-in freezer, in the kitchen, revealed the following unlabeled and undated items: 2 bags of frozen spinach and 1 bag of frozen okra. The following items were not stored properly in the walk-in freezer; 1 box of opened and uncovered/unsealed cookie dough and 1 box of open and uncovered/unsealed breaded fish patties. Observation on 05/04/2025 at 10:50 AM of the walk-in refrigerator in the kitchen, revealed the following unlabeled and undated items: 1 pitcher of prepared tea, 1 container of an unknown yellow liquid, and 1 container of vegetable soup. The walk-in refrigerator also contained the following outdated items: 1 container of tomato soup (expired 05/03/2025), and 1 container of chicken noodle soup (expired 05/03/2025). During an interview on 05/04/2025 at 11:00 AM the DM stated she was unaware of the facility's policy regarding timeframes of holding prepared food in the refrigerator. The DM stated she had her staff throw out any prepared foods on Mondays unless the prepared food looked bad prior to that. The DM stated she believed the holding timeframe for prepared food was 4 to 5 days in the refrigerator. The following observations and interviews were made on 05/05/2025 beginning at 11:22 AM during a follow-up observation of the kitchen: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 24 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 Observation on 05/05/2025 at 11:22 AM of the walk-in refrigerator in the kitchen, revealed the following outdated item: 1 container of chicken noodle soup (expired 5/3/2025). The walk-in refrigerator also contained one unlabeled and undated container of a brown pudding-like substance. During an interview on 05/06/2025 at 1:00 PM the DM stated all food in the kitchen refrigerators should have been dated with a prepared date or an expiration date. The DM stated all dietary staff were responsible for ensuring food was labeled and dated. The DM stated all dietary staff received training on food preparation and storage upon hire and again during in-service trainings. The DM stated it was her expectation that regulations were followed, and food items were labeled and dated properly. The DM stated all expired food should have been discarded each day. The DM stated she was not aware there was any expired food or food stored improperly in the refrigerator, freezer, or dry pantry. The DM stated she would complete an in-service with all dietary staff to educate them on proper food storage and holding timeframes for the refrigerator. The DM stated it was important for food items to be labelled and dated to ensure outdated food was not being served to prevent foodborne illness. The DM stated when food was not labelled and dated properly, residents were at risk of getting sick. During an interview on 05/06/2025 at 2:20 PM the DON stated she was unsure of the facility's food storage policy. The DON stated all food in the refrigerators and freezers should have been labelled and dated. The DON stated she did not know what training dietary staff received. The DON stated all dietary staff were responsible for ensuring food was stored properly. The DON stated expired food should not have been stored in the refrigerators. The DON stated there was a risk that expired food could be served to residents if it was not stored properly. The DON stated residents were at risk of getting sick if they were served food that was not stored properly or expired. During an interview on 05/06/2025 at 2:42 PM the ADM stated he was unsure of the facility's policy regarding food storage and holding times for prepared food. The ADM stated all food in freezers, refrigerators, and the dry pantry should have been labelled and dated and discarded promptly. The ADM stated it was his expectation that all food was served fresh and stored properly. The ADM stated all dietary staff were responsible for ensuring food was stored and dated properly, and the DM was responsible for overseeing dietary staff. The ADM stated the DM was responsible for checking all food storage areas to ensure food was stored properly. The ADM stated dietary staff received training upon hire and received in-service trainings if issues arose. The ADM stated if food was not labelled or dated properly, residents could have received food that was not fresh and outdated which could have potentially caused illness to the resident. Record review of the undated facility policy titled Food Storage did not contain any information pertaining to dating and/or labeling items. The facility stated they did not have any additional policies pertaining to food storage. The Food Storage policy revealed the following documentation: POLICY: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. PROCEDURES: 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 25 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The dietary manager, or his/her designee, will check refrigerators and freezers at least daily. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 26 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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, facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 3 of 4 residents (Resident #32, Resident #35, Resident #67, and Resident #90) and 5 of 6 staff (LVN A, LVN D, CNA D, CNA E, and CNA F) reviewed for infection control. Residents Affected - Some 1. LVN A failed to follow facility policy and procedure for handwashing while providing wound care for Resident #32, during observations of wound on 05/05/2025 at 2:33 PM. 2. CNA D and CNA E failed to follow facility policy and procedure for handwashing while providing incontinent care for Resident #35, during observations of incontinent care on 05/05/2025 at 10:34 AM. 3. The facility failed to provide an enhanced barrier precautions sign for Resident #67 while having a wound. LVN D, CNA D, and CNA E all provided direct care without PPE due to an enhanced barrier precaution sign not being posted. 4. CNA F failed to follow facility policy and procedure for handwashing while providing incontinent care for Resident #90, during observations of incontinent care on 05/05/2025 at 11:22 AM. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #32 Record review of Resident #32's face sheet undated revealed an [AGE] year-old female with an admission date of 11/08/2023 with the following diagnoses: Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls), pressure ulcer of right buttock (stage 3), pressure ulcer of sacral region (stage 3), dysphagia (difficulty swallowing), cognitive communication deficit, anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), type 2 diabetes, vitamin deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acid reflux, muscle weakness, osteoporosis (a condition in which bones become weak and brittle). Record review of Resident #32's admission MDS dated [DATE] revealed a BIMS score blank and incomplete. The MDS under unhealed pressure ulcers, Resident #32 was listed as a 0, meaning that Resident #32 was not at risk of pressure ulcers at the time of the MDS. Under unhealed pressure ulcers/injuries Resident #32 was listed as a 0 meaning that Resident #32 was not listed as having a pressure ulcer/injury at the time of the MDS. Under current number of unhealed pressure ulcers/injuries at each stage was left blank and incomplete. Under skin conditions the section was left blank and incomplete. Record review of Resident #32's Care Plan dated 12/27/23, revealed that Resident #32 was listed as having a potential for pressure ulcer development with the interventions of: follow facility policies/protocols for the prevention/treatment of skin breakdown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 27 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 Physician Orders for Resident #32, dated 02/24/25, stated: Wound care to stage 3 pressure injury to sacrum; cleanse with normal saline, pat dry, apply calcium alginate, cover with silicone super absorbent dressing. During an observation of wound care on 05/05/2025 at 2:33 PM, LVN A washed her hands for 10 seconds with soap/friction before rinsing her hands under running water. LVN A used a clean paper towel to dry her hands. LVN A used a clean paper towel to turn off the faucet and disposed in the trash. LVN A put on a pair of clean disposable gloves. LVN A used a disinfectant wipe to clean the tray to set up supplies. LVN A removed and disposed of gloves. LVN A washed her hands with hand sanitizer. LVN A put on pair of clean gloves. LVN A had used a disinfectant wipe to clean the bedside table. LVN A had not put on PPE when Resident #32 was listed as enhanced barrier precautions due to wounds. LVN A removed dirty gloves and disposed in the trash. LVN A washed her hands with soap/friction for 8 seconds prior to rinsing them under running water. LVN A used a clean paper towel to dry her hands. LVN A used a clean paper towel to turn off water faucet and disposed in the trash. LVN A set up all wound care supplies, specified in orders, on the bedside table. LVN A removed disposable gloves and disposed in the trash. LVN A used hand sanitizer to wash her hands. LVN A grabbed a PPE gown (yellow) and put it on. LVN A put on clean pair of disposable gloves. LVN A grabbed a biohazard bag and opened it to be ready to place trash in the bag. Resident #32 was sitting in her wheelchair and LVN A had Resident #32 stand up and bend over while holding onto the bed. Resident #32 did not seem stable. LVN A pulled Resident #32's pants down and removed the brief. LVN A removed the dirty bandage and disposed in the trash. LVN A removed her dirty disposable gloves and disposed of them into the trash. LVN A washed her hands with soap/friction for 9 seconds before rinsing them under running water. LVN A used a clean paper towel to dry her hands. LVN A used a clean paper towel to turn off the faucet and disposed in the trash. LVN A provided wound care according to physician orders. LVN A removed gloves and disposed in the trash. LVN A used hand sanitizer to wash her hands. LVN A put a clean pair of disposable gloves on. LVN A put calcium alginate and bandage on the wound. LVN A placed on new brief on Resident #32 and pulled up Resident #32's pants. LVN A used hand sanitizer to wash her hands. LVN A put on clean gloves. LVN A gathered the trash and disposed of the trash. LVN A did not wash her hands after disposing the trash. During an interview on 05/06/2025 at 3:25 PM, LVN A stated that the policy for handwashing states to wet hands, put soap on hands and scrub for 15 to 20 seconds, thoroughly rinse hands, use a clean paper towel to dry hands, and then use a clean paper towel to turn off the faucet. LVN A stated that by following the policy it helps to prevent contaminating any germs on the hands and transferring germs to the resident that may cause harm. LVN A stated that she had training in infection control and handwashing through in-services, monthly. LVN A stated that she had competency checks for handwashing, yearly. LVN A stated that it was the responsibility of the ADON and DON to oversee the training. Resident #35: Record review of Resident #35's face sheet dated 05/06/2025 revealed a [AGE] year-old female with an original admission date of 0/9/03/2020 and an initial admission date of 10/08/2019 with the following diagnoses: Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, need for assistance for personal care, dementia, dysphagia (difficulty swallowing), depression, diarrhea, chronic kidney disease, anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), atherosclerotic heart disease, attention and concentration deficit, osteoporosis, unsteadiness on feet, gastrointestinal hemorrhage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 28 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 2 meaning that Resident #2 had severe cognitive impairment. The MDS under bowel and bladder, Resident #35 was listed as a 3 meaning always incontinent. Record review of Resident #35's Care Plan dated on 09/10/2020, revealed that Resident #35 was listed as having bowel and bladder incontinence with the goal listed as: check as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. During an observation of incontinent care on 05/05/2025 at 10:34 AM, CNA D washed hands with soap/friction for 8 seconds before rinsing hands thoroughly under running water. CNA D used a clean paper towel to dry hands and disposed in the trash. CNA D used a clean paper towel to turn off the water faucet and disposed in the trash. Helper CNA E had then washed her hands with soap/friction for 16 seconds before rinsing her hands under running water. CNA E used a clean paper towel to dry hands and disposed in the trash. CNA E used a clean paper towel to turn off the water faucet and disposed in the trash. CNA D gathered supplies for incontinent care. CNA D washed hands with soap/friction for 10 seconds before rinsing hands under running water. CNA D used a clean paper towel to dry hands. CNA D used the same paper towel that was used to dry her hands to turn off the water faucet. CNA E did not wash her hands. CNA D removed the resident's blankets. CNA D laid towel behind the resident. CNA E unfastened and removed Resident #35's brief. CNA D used one wipe to wipe the right crease of groin area and disposed in the trash. CNA D used one wipe to wipe the left crease of groin area and disposed in the trash. CNA D used one wipe to wipe across the top groin area and disposed in the trash. CNA D used one wipe to wipe center vagina and repeated this step three times due to bm. CNA D removed gloves and disposed in the trash. CNA D used hand sanitizer to wash her hands instead of using soap and water after having visible BM. CNA D put on pair of clean gloves. CNA E turned resident to the side. CNA D used one wipe to clean the right buttock and disposed in the trash. CNA D used a clean wipe to clean the left buttocks and disposed in the trash. CNA D used a clean wipe to clean the anus and there was a large amount of BM. CNA D only wiped one time and left BM on the resident. CNA D removed gloves and disposed in the trash. CNA D used hand sanitizer to wash her hands instead of using soap and water after wiping BM. CNA D put on a pair of clean disposable gloves. Surveyor intervened and asked CNA D to wipe to verify if the resident was clean. There was still a large amount of bm on the resident. CNA D had to clean with an additional four wipes until Resident #35 was clean. CNA D then placed a clean brief behind resident and laid her back. CNA D pulled up the front side of the resident's brief and fastened. CNA D dressed the resident, covered the resident, and gathered the trash. CNA D removed gloves and disposed in the trash. CNA D washed her hands with soap/friction for 10 seconds before rinsing her hands under water. CNA D used a clean paper towel to dry her hands and used the same paper towel to turn off the water faucet and disposed in the trash. CNA E did not wash her hands. During an interview on 05/06/2025 at 1:51 PM, CNA D stated that the policy for handwashing stated to scrub finger, hands, and nails for 15 to 20 seconds. CNA D stated that she had been trained in handwashing and infection control through company videos, and in-services. CNA D stated that she had competency checks monthly as well as all other training. CNA D stated that the DON and the ADON had been responsible for overseeing the training. CNA D stated that she was just nervous and in a hurry. CNA D stated that it was important to provide handwashing per policy because you could pass infections and germs to the residents. CNA D stated that the resident's immune system was fragile. CNA D stated that what she would have done different would be keep a steady pace, make sure to clean the resident, and wash hands as the policy stated. During an interview on 05/06/2025 at 3:47 PM, CNA E stated that the policy stated that you should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 29 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 wash your hands before, during, and after providing care for a resident for 15 to 20 seconds. CNA E stated that she had been trained in infection control practices and handwashing through in-services, Relias, and refreshers, every few weeks. CNA E stated that she was nervous, and her mind went blank. CNA E stated that the negative potential outcome of not providing handwashing as the policy stated could cause the spread of infections. Residents Affected - Some Resident #67: Record review of Resident #67's face sheet undated revealed a [AGE] year-old male with an admission date of 04/22/2024 with the following diagnoses: stroke, muscle weakness, pressure ulcer of left buttock (stage 3), pressure ulcer of other site (stage 3), dysphagia (difficulty swallowing), need for assistance with personal care, major depressive disorder, hyperlipidemia, acid reflux, tinea unguium (nail fungus causing thickened, brittle, or ragged nails), retention of urine, Alzheimer's disease, atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), systolic heart failure, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #67's quarterly MDS dated [DATE] revealed a BIMS score listed as 3 meaning Resident #67 had severe cognitive impairment. The MDS under skin conditions showed that Resident #67 was not at risk, nor did he have a pressure ulcer. Record review of Resident #67's Care Plan dated 11/24/24, revealed that Resident #67 was listed as having actual impairment to skin integrity with stage three pressure injury to the sacrum. The goal listed was reduce risk for impairment to skin integrity through the use of wound care as ordered, offloading wound bed, supplements, frequent repositioning through the review date. Record review of Resident #67's Care Plan dated 05/21/24, had the potential for pressure injuries due to mobility. Record review of Resident #67's Physician Orders, dated 04/18/2025, stated: pressure wound to sacrum. Cleanse with normal saline or wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent dressing as needed. Record review of Resident #67's Physician Orders, dated 04/18/2025, stated: pressure wound to sacrum. Cleanse with normal saline or wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent dressing, day shift. Observation and interview during wound care on 05/05/2025 at 10:08 AM, Resident #67 did not have enhanced barrier precautions posted on the door, prior to observations of wound care. There was no hand sanitizer dispenser in Resident #67's room or outside of the door. Surveyor asked wound care nurse if Resident #67 was listed as enhanced barrier precautions. The Wound care nurse had stated yes and that all resident's with wounds or catheters were listed as enhanced barrier precautions. The Wound care nurse used the appropriate PPE to treat Resident #67. When asked about the enhanced barrier precautions that was supposed to be posted, wound care nurse stated that she was unsure why there was not a posting on the door. There was no PPE bin outside of Resident #67's room. During an observation on 05/06/2025 at 12:00 PM, Resident #67 still had no enhanced barrier precaution sign posted on the door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 30 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/06/2025 at 12:10 PM, LVN D stated that she was not sure why Resident #67 did not have an enhanced barrier precautions sign posted on the door. LVN D stated that if Resident #67 was supposed to have a sign then he should have an enhanced barrier precaution sign posted. LVN D stated that she did not realize that Resident #67 was on enhanced barrier precautions. LVN D stated an enhanced barrier precaution sign shows that staff need to wear certain PPE to provide direct care to the resident in order to protect the resident and staff against infections. LVN D stated that by not taking precautions residents wounds could worsen or staff could give something to the resident. LVN D stated that she would ask ADON why Resident #67 did not have a sign. During an interview on 05/06/2025 at 12:10 PM, the ADON stated that Resident #67 had a wound on the coccyx. The ADON stated that Resident #67 should have had an enhanced barrier precaution sign posted. The ADON stated that he did not know why there was not one posted, but would make sure to get one posted, immediately. The ADON stated that if there was not a sign posted then that could have caused a spread of infection in the resident's wound. During an observation on 05/06/2025 at 1:48 PM, rooms #200, #202, #203, and #208 did not have hand sanitizer dispensers in the room or in the hall, all listed as enhanced barrier precautions. During an interview on 05/06/2025 at 1:51 PM, CNA D stated that she was not aware that Resident #67 was supposed to be on enhanced barrier precautions. CNA D stated that she was the caregiver on this hall and did provide care to Resident #67. CNA D stated that she knew that Resident #67 did have a wound but did not know that he was supposed to have been on enhanced barrier precautions. CNA D stated that she did not wear any PPE besides gloves to provide care to Resident #67 because she had not known that he was on enhanced barrier precautions. CNA D stated that by not wearing the appropriate PPE to provide care for Resident #67, it could have made wounds worse or spread infections. CNA D stated that no one had told her that Resident #67 was supposed to have been on enhanced barrier precautions. CNA D stated that she was not sure why there was not any hand sanitizer dispensers on this hall. CNA D stated that she had always brought her own hand sanitizer, so she had not paid any attention to the dispensers. During an interview on 05/06/2025 at 3;47 PM, CNA E stated that she was assigned to work hall 200 and had provided care to Resident #67. CNA E stated that she was not aware that he was supposed to be on enhanced barrier precautions. CNA E stated that she was aware that Resident #67 had a wound. CNA E stated that she had not worn PPE for enhanced barrier precautions because she had not known Resident #67 was on barrier precautions. CNA E stated that by not wearing PPE for residents on enhanced barrier precautions could cause the spread of infections. Resident #90: Record review of Resident #90's face sheet undated revealed a [AGE] year-old female with an admission date of 03/08/2025 with the following diagnoses: constipation, urinary tract infection, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), severe sepsis (a life-threatening complication of an infection), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), acute diastolic heart failure, hemoperitoneum (a life-threatening condition that occurs when blood accumulates in the heart's pericardial sac), acute kidney failure with tubular necrosis, neuromuscular dysfunction of bladder, dysphagia (difficulty swallowing), need for assistance with personal care, anemia (condition in which the blood does not have enough healthy red blood cells and hemoglobin), pneumonia, overactive bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 31 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #90's quarterly MDS dated [DATE] revealed a BIMS score listed as 5 meaning severe cognitive impairment. The MDS under bowel continence Resident #90 was listed as a 3 meaning always incontinent. During an observation of incontinent care on 05/05/2025 at 11:22 AM, CNA F did not wash her hands prior to gathering incontinent supplies. CNA F put on yellow gown for PPE due to enhanced barrier precautions. CNA F washed her hands after gathering incontinent supplies by using soap/friction for 11 seconds before rinsing her hands under running water. CNA F used a clean paper towel to dry her hands and disposed in the trash. CNA F used a clean paper towel to turn off the water faucet and disposed in the trash. CNA F laid out supplies on the bedside table using a towel as a barrier. CNA F removed her PPE (gown and gloves) and disposed in the trash to leave the resident's room to get hand sanitizer. CNA F came back into the resident's room after grabbing a bottle of hand sanitizer. CNA F washed hands with soap/friction for 6 seconds before rinsing her hands under running water. CNA F used a clean paper towel to dry her hands and disposed in the trash. CNA F used a clean paper towel to turn off the water faucet and disposed in the trash. CNA F uncovered Resident #90 and removed her pants. CNA F unfastened the resident's brief. Observed a large amount of BM on Resident #90. CNA F used the brief to wipe the majority of the bm off of the resident. Observed CNA F disposable gloves were soiled. CNA F removed disposable gloves and disposed in the trash. CNA F used hand sanitizer to wash her hands. CNA F put on clean pair of disposable gloves. CNA F used one wipe to wipe the center anus area and disposed of wipe in the trash. CNA F used another clean wipe to repeat this process and then proceeded to fold that same wipe and repeat the process of cleaning. CNA F then disposed of the wipe in the dirty brief by folding the dirty wipe into the dirty brief. CNA F then discarded the dirty brief into the trash bag. CNA F removed dirty gloves and discarded in the trash. CNA F washed hands with soap/friction for 4 seconds before rinsing hands under running water. CNA F used a clean paper towel to dry her hands and then disposed in the trash. CNA F used a clean paper towel to turn off faucet and disposed in the trash. CNA F put on a pair of clean disposable gloves. CNA F laid Resident #90 on her back and proceeded to provide peri care to the front area of the resident. CNA F noticed that there was also BM on the front side of the resident. CNA F wiped the vagina opening and noticed BM, wiped with a wipe, and discarded in the trash. CNA F removed gloves and discarded in the trash. CNA F used hand sanitizer to wash hands. CNA F put on a pair of clean disposable gloves. CNA F used a wipe to clean the vagina opening again and disposed of the wipe in the trash. CNA F used hand sanitizer to wash her hands. CNA F put on a clean pair of disposable gloves. CNA F used a wipe to clean the catheter tubing and discarded the wipe in the trash. CNA F removed her gloves and disposed in the trash. CNA F washed hands with soap/friction for 7 seconds before rinsing hands under running water. CNA F used a clean paper towel to dry hands and disposed in the trash. CNA F used a clean paper towel to turn off the water faucet and disposed in the trash. CNA F put on pair of clean disposable gloves. Surveyor noticed the Resident #90 had dried BM on the side of the resident's leg. CNA F turned resident back to the side to clean Resident #90 some more because CNA F realized that she did not clean all of the BM off of the resident. CNA F used 2 wipes to clean the backside of Resident #90. CNA F folded the dirty wipe and wipes continuously trying to get the dried BM off of the resident. CNA F used the same wipe to wipe 12 times. CNA F removed the dirty gloves and disposed of them in the trash. CNA F used hand sanitizer and put on a pair of clean disposable gloves. CNA F put a clean brief on Resident #90. Observed BM on sheets. CNA F grabbed a clean draw sheet and covered the soiled sheets with the clean draw sheet. CNA F dressed Resident #90. CNA F gathered dirty laundry and trash. CNA F washed hands for 9 seconds with soap/friction before rinsing her hands under running water. CNA F used a clean paper towel to dry her hands and disposed in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 32 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 trash. CNA F used a clean paper towel to turn off the faucet and disposed in the trash. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/06/2025 at 2:29 PM, CNA F stated that the policy for handwashing had stated to sing happy birthday while washing hands and that should be sufficient. CNA F stated that she did not know a specific time limit of what the policy states for how long you should wash your hands. CNA F stated that she should have made sure to wash hands properly. CNA F stated that she should have made sure to verify that Resident #90 was completely clean from all BM and urine before competing care. CNA F stated that she did not do what the policy stated because she was nervous. CNA F stated that the importance of making sure that the procedure was done per the policy was that it prevents the spread of infections or cross contamination. CNA F stated that she had training for infection control practices and hand washing through in-services, modules, and skills checks, every three months. CNA F stated that it was the responsibility of the ADON and DON to oversee the training. Residents Affected - Some During an interview on 04/15/2025 at 2:00 PM, The Administrator stated that the policy stated that we should wash hands long enough and per policy. The Administrator stated that it was the responsibility of the nurse managing team and DON to oversee the training. The Administrator stated that competency checks were completed monthly. The Administrator stated that his expectations were for staff to follow policy. The Administrator stated that the negative potential outcome for not following infection control practices was the spread of infections. During an interview on 05/06/2025 at 4:23 PM, The DON stated that her expectations for staff would be to follow policy for hand washing and infection control practices. The DON stated that staff should wash their hands before, during and after providing direct care for at least 15 seconds. The DON stated that the negative potential outcome for not following the handwashing and infection control policy would be the spread of infections. The DON stated that training was provided to the staff for infection control practices and handwashing through in-services, company, and competency checks, monthly. The DON stated that it was the responsibility of the DON and ADON to oversee the training. Record review of the facility-provided policy titled, Handwashing, dated 06/2016, revealed: Policy: It is the policy of this community to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Hand washing is considered the most important single procedure for preventing the spreading of infections. Procedure: 1. Wet hands and apply soap to hands. 2. Rub hands in circular motion for not less than fifteen (15) seconds, using friction. 3. Rinse hands with warm water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 33 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 4. Level of Harm - Minimal harm or potential for actual harm Dry hands with paper towel. 5. Residents Affected - Some Tum off faucet with paper towel. 6. Discard paper towel in appropriate receptacle Waterless hand washing procedure: 1. Some situations require hand washing in areas where sinks are not readily available. In these limited circumstances, waterless hand washing products may be used. These products are not a substitute for good hand washing. Hand washing with soap and water should be done as soon as possible. 2. Waterless hand washing products are not used for skin care treatments or administration of eye drops. Record review of the facility-provided policy titled, Perineal Care, undated, revealed: Policy: It is the policy of this facility to: 1. Cleanse perineum 2. Eliminate odor 3. Prevent irritation or infection 4. Enhance resident's self-esteem Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 34 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 Equipment: Level of Harm - Minimal harm or potential for actual harm Washcloth and towel Disposable wipes may be used as a substitute for soap and water. Residents Affected - Some 1. Use privacy curtain for resident privacy. 2. Identify resident. 3. Explain procedure. 4. Gather necessary equipment. 5. Wash hands properly. Note: The basic infection control-concept for peri care is to wash from the cleanest area to the dirtiest area. 1. Rinse cloth and proceed with cleansing of the anal area, as described above. For all variations, complete procedure as follows: o Discard equipment or return it to the appropriate location. o Wash hands properly. o Document all appropriate information in medical record. Record review of the facility-provided policy titled, Wound Care, undated, revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 35 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 Policy: It is the policy of this facility to provide excellent wound care to promote healing. Level of Harm - Minimal harm or potential for actual harm Procedure: 1. Residents Affected - Some Supplies are never placed on the bed. The soiled trash bag may be. 2. Supplies should be placed on a clean surface. A blue pad provides a nice clean barrier. 3. Hand washing must be done as outlined in the procedure. 4. The resident must not be soiled when the dressing change is done. Record review of the facility-provided policy titled, Infection Control, undated, revealed: Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goals: o Decrease the risk of infection to residents and personnel. o Recognize infection control practices while providing care. o Identify and correct problems relating to infection control. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 36 of 37 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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 Ensure compliance with state and federal regulations related to infection control Level of Harm - Minimal harm or potential for actual harm o Residents Affected - Some Promote individual resident's rights and well-being while trying to prevent and control the spread of infection. o Monitor personnel health and safety. 3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Policy for Enhanced Barrier Precautions was requested on 05/06/2025, the Administrator did not provide the policy and stated that he had not further documents to provide at that time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 37 of 37