Health inspection·August 22, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few review of Resident #1's progress note dated 8/8/25 at 7:10AM revealed X ray to the Right Knee to R/O Dislocation. pt Stated she heard a loud pop when transferring to bed last HS, she c/o to this nurse this morning that she was in pain, and she couldn't move her leg. This nurse medicated pt for pain level 10 and notified NP. requested X ray to R/O Dislocation of the RT knee. STAT signed by RN H. Progress note dated 8/8/25 at 10:56 AM revealed Per [MD] sent pt to [hospital] to get tx and evaluate for the rt knee fx signed by RN H. Record review of Resident #1's radiology report dated 8/8/2025 10:02AM revealed Impressions: 1. Osteoporosis 2. The knee arthroplasty is aligned (the specific way the new knee joint components are positioned during surgery to restore function and balance) 3. The acute distal femoral metaphyseal [the wider portion of a bone] fracture is visualized with posterior displacement (distal femoral metaphyseal fracture with posterior displacement is a serious injury to the thigh bone, just above the knee. Posterior displacement means the broken end of the thigh bone has shifted backward towards the back of the knee). Record review of Resident #1's hospital records revealed Date of admission: [DATE]; History of present illness: presents to [hospital] ED (emergency department) via EMS (emergency medical services) with complaints of right knee pain. Patient states that she fell yesterday when trying to transfer to the shower with the assistance of nurse aide and lost balance causing her to fall and hit the right side of her body. Patient denies pain to her remaining extremities. Denies hitting her head. Denies blood thinner use. Denies blurry vision or headache. Denies numbness or tingling. States that her functional status prior to injury was ambulatory with assistive device and occasional wheelchair use. Diagnostic Studies: [X-ray] acute distal femoral fracture.Date: 08/08/25, open reduction internal fixation of right periprosthetic supracondylar distal femur fracture (surgical repair of distal femur).During an interview with Resident #1's family member on 8/20/2025 at 7:10pm, she stated Resident #1 had a fall on 8/7/2025 and had sustained a broken distal femur. She stated Resident #1 had called her on 8/8/2025 about the fall and that Resident #1 told her during the night a CNA was attempting to take her to the shower and during the transfer Resident #1 fell and her knee popped. Resident #1's family member stated she was not sure if the CNA was unable to handle Resident #1's weight or why they had only sent one person to assist Resident #1 but she was upset that the incident had happened on 8/7/2025 but nothing was done until 8/8/2025. She stated she was notified by the facility around 10AM on 8/8/25 that Resident #1 had notified the morning nurse of her knee popping and they obtained an x-ray showing a fracture to the right knee. She stated Resident #1 was sent out to the hospital where she had to have surgery to the right knee to repair the fracture. She stated she did speak to the morning nurse and she was made to feel as though it was Resident #1's fault because she was told this occurred due to Resident #1 attempting to self-transfer. She stated she wanted to know what had actually happened because she did not believe Resident #1 would be lying about having a fall. She stated Resident #1 also complained of being in pain and not having received any pain medication through the night to alleviate the pain in her knee. During an interview with Resident #1 on 8/20/2025 at 8:45PM, she stated she didn't remember when the incident occurred or with who, but she remembers it was at night and the CNA had come to help her into her wheelchair. She stated she is not sure what happened, but the CNA was unable to hold her weight and they both fell together onto the floor. She stated she heard her knee pop after they fell. She stated the CNA went to get help and returned with another CNA and between both of them they assisted her back into bed. She stated she does not remember anyone checking on her through the night and she complained of her right knee hurting. Resident #1 stated she did not want any of the CNAs to get in trouble. She stated she told them her knee had popped and the morning nurse gave her pain medication, called the doctor and they sent her to the hospital. She stated at the hospital she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 2 of 18 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 08/22/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few surgery on her right knee. She stated she really cares for the staff and did not want anyone to get in trouble and understood it was an accident. During a second interview with Resident #1 on 8/21/2025 at 1:20pm, she stated the night of the incident, she had been in pain the entire night and does not remember getting any pain medication. She stated the incident made her feel bad and in pain. She stated prior to the incident she had no issues with the staff and since she has been back, all her needs are being met. During an interview with LVN A on 8/20/2025 at 9:29pm, she stated she was working 8/7/2025 and worked with Resident #1. She stated on 8/7/2025, no report of an injury or fall had been reported to her by anyone. She stated the CNAs were usually really good about reporting any minor event or any falls. She stated if she knew someone had a fall, she would go assess and notify the physician and family. She stated she does remember checking in on Resident #1 during the night of 8/7/2025 but does not remember giving her any pain medication. She stated she does not remember who called her on 8/8/2025 but they asked if Resident #1 had any injuries or falls during the night shift, and she stated she was not aware of any events for that night. She stated the week of 8/11/2025, she had heard from CNA K, that CNA C had mentioned falling with Resident #1 prior to her going to the hospital. She stated she did not report that to the DON or ADM because Resident #1 was already at the hospital, and she believed it had already been addressed. During an interview with CNA B on 8/20/2025 at 9:42AM, she stated she was working on 8/7/2025 with LVN A. She stated she usually works with Resident #1. She stated on 8/7/2025 she did report that Resident #1 mentioned having a fall, to LVN A. She stated LVN A said no one had mentioned a fall to her. She stated she also mentioned to LVN A that Resident #1's knee was hurting. CNA B stated she did check on Resident #1 through the night and she complained about her knee and Resident #1 stated something feels wrong. CNA B stated Resident #1 did not detail how she fell only that her knee hurt. CNA B stated she did see LVN A go into Resident #1's room but did not know for what. CNA B stated she never went into Resident #1's room to assist her from any fall or assist her back into bed. CNA B stated she did hear from CNA K that Resident #1 had a fall with another CNA, but did not know what CNA. She stated she heard this the week after Resident #1 had been sent to the hospital. She stated she did not report that because she believed it had been addressed already. She stated she had been trained on reporting falls and accidents to her nurse. She stated she did let LVN A know about Resident #1 stating she had a fall.During an interview with the ADM on 8/20/2025 at 10:20pm, he stated no staff member had reported a fall with Resident #1 on 8/7 or 8/8. He stated on 8/8/2025 he learned of Resident #1's fracture and he spoke to Resident #1 himself. He stated at that time, Resident #1 told him, she had attempted to self-transfer into her wheelchair and heard her knee pop and sat back down in bed. He stated he did ask the night staff from 8/7/2025 if there had been any incidents or injuries with Resident #1 and no one reported any falls or injuries. He stated this was his first time learning of a potential fall. He stated if the CNAs working that night were aware Resident #1 had any form of change in condition, injury or had an incident, it should have been reported to the nurse and addressed that night with the physician and notified family. He stated at the time of the incident, there was no DON at the facility. He stated the current DON began his role on 8/15/2025. During an interview with CNA C on 8/21/2025 at 8:48AM, she stated she had been working at the facility for the past two months and she was responsible for showers. She stated on 8/7/2025, she was assisting Resident #1 from the bed to the wheelchair to take her for her shower at approximate 9pm. She stated Resident #1 is a minimum assistance transfer and usually does very well pivoting from bed to her wheelchair. She stated she noticed Resident #1 appeared to be struggling so she got behind her and tried to hold her, but she heard Resident #1's knee pop. She stated she pulled Resident #1 towards her, and they both slid down to the floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 3 of 18 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 08/22/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few together. She stated after they were both on the floor, Resident #1 was complaining about her right knee hurting. She stated she had been trained not to move residents after a fall and had gone to look for a nurse. She stated she was unable to find a nurse, and Resident #1 pushed her call light. She stated Resident #1 wanted to get back in to bed. She stated she went and grabbed CNA B to help her get Resident #1 back in bed and they both assisted Resident #1 back to her bed. She stated her shift ended at 10pm and she went home. She stated she did not see any nurses on her way out and did not report the incident to anyone except CNA B. She stated she was trained to report these incidents so the residents can have the proper assessments. She stated, I feel like I could have done something different in this case, I would have tried to find a different nurse on a different hallway. CNA C stated she was not aware Resident #1 had been sent to the hospital for a broken femur and required surgery. During an interview with CNA K on 8/21/2025 at 9:09AM, she stated she had heard about Resident #1 having a fall from report. She stated she did not remember who told her but she was making sure to pass the information down during report. She stated she does not usually work the hall Resident #1 is on, but that she had worked with her in the past. She stated when she asked where she was, that is when she was told Resident #1 had a fall and was at the hospital. She stated she was here on 8/7/2025 but did not know of any fall that day but if a fall had occurred it should have been reported as soon as possible. She stated she was not present for a fall, and did not know any details about the fall, only that Resident #1 had a fall. During an interview with the MD on 8/22/2025 at 11:00AM, he stated he had been made aware of Resident #1's knee hurting after a bed to wheelchair transfer [8/8/2025]. He stated from his understanding Resident #1 was transferring and heard a pop and was sat down in the wheelchair. He stated he had not been aware the incident occurred the night before and staff should have notified him that night [8/7/2025]. He stated he expects staff to notify him of any incidents or injuries as soon as possible. Record review of facility policy titled Change in Condition, last revised 4/2025 revealed .1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identity need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using telephone or similar process to obtain new orders or interventions. Record review of facility policy titled Fall Management System last revised 4/2025 revealed; Fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force.3. When a Resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.a. The Attending Physician and Resident Representative shall be notified of the fall and the resident status. B. Follow-up documentation will be completed for a minimum of 72 hours following the incident.5. The investigation will be reviewed by the interdisciplinary Team. The ADM and DON were notified an IJ situation was identified due to the above failures on 08/21/25 at 2:51 PM and the IJ template was provided. The following Plan of Removal was accepted on 8/21/25 at 6:13 PM: F-580-Failure to NotifyPlan of Removal8/21/25Per the information provided in the IJ template given on 8/21/25 at 2:51. The facility failed to properly notify the charge nurse, and MD of an incident with Resident #1 when resident #1 heard her knee pop and had to be guided down to the floor. Immediate Actions Taken:1. Head to toe assessment was completed on resident #1.2. Suspension of C.N.A. C on 8/20/253. Safe Surveys completed on 8/21/25Others who have the potential to be affected by this deficient practice: All residents have the potential to be affected by this deficient practice.1. The Medical Director was notified of IJ on 8/21/25 by the Executive Director [ADM].2. Education (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 4 of 18 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 08/22/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few initiated with licensed nurses and certified nursing assistants [NAME]. Reporting any change of condition to the charge nurseb. Abuse and Neglect3. Quiz was completed on 8/21/25 to C.N.A's currently on shift to indicated competency.4. All quizzes and competencies for C.N.A.'s will be completed by 8/22/25.5. This training and competencies have been completed with current C.N.A staff on 8/21/25. A member of management will be at the facility at each change of shift. C.N.A will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the nursing new hire orientation and C.N.A's will not be allowed to work unless they have received their training and knowledge check.6. An ad hoc (as needed) meeting regarding items in the IJ template was completed on 8/21/25 with complete policy review. Attendees included the Medical Director, Executive Director-[facility] [ADM], Executive Director [corporate], Director of Nursing-[facility], Director of Nursing [corporate], Clinical Market Leader and Clinical Resource.7. The DON, ADON will verify C.N.A competency with C.N.A's weekly.8. All residents with new complaints of pain or injury will be reviewed by DON, ADON ordesignee every week in the clinical meeting to ensure that all parties have been notified of a new injury or new complaint of pain.9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance.On 08/22/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. Record Review of document tiled Skin Evaluation dated 8/21/2025 1500 [3pm] for Resident #1 revealed: Resident noted resting in bed upon enter. Skin assessment completed by this DON. Post surgical wound noted to right thigh, dressing CDI (clean, dry, intact).Full head to toe assessment completed and no other concerns or issues noted at this time, signed by DON on 8/22/2025. 2. Record review of document titled View Event revealed: For [CNA C].last day of work: 8/20/2025, first day of leave: 8/21/2025.leave type: Suspension.3. Record review revealed Safe Surveys dated 8/20/2025 had been conducted with 83 Residents in the facility. Safe Survey documents revealed all 83 residents stated yes they felt safe at the facility, and they report abuse to the administrator. They all stated yes, staff treated them with dignity and respect, and they felt their needs and concerns were reported to the appropriate parties. Record review revealed Pain evaluation in Advanced Dementia assessments were completed for 31 Residents in the facility on 8/20/2025. All 31 Resident assessments revealed breathing normal, no negative vocalization, facial expressions; smiling or inexpressive, body language; relaxed and consolability; no need to console. 4. During an interview with the MD on 8/22/2025 at 11:00AM he stated he was notified of the IJ templates, and the facility had a QAPI meeting, and they had implemented a plan of removal. He stated the facility would be implementing more training and education on abuse and neglect and on reporting any changes in condition. He stated they would continue to review through QAPI meetings for effectiveness. 5. Record review of facility document titled Inservice Title: Reporting Allegations and Suspicions of abuse or neglect and change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed .Any change in condition should be reported to the Provider as well as the DON and ADON immediately. 6. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L ,M ,N ,P, Q, R, S ,T, GVN F, CMA G, LVN E, I,J, O, and RN H revealed all staff members had been trained on reporting any changes in conditions such as falls, injuries or incidents. All CNAs, and CMAs stated they would report any changes in condition to the charge nurse or the DON. All licensed nursing staff stated they would report any changes in conditions to the physician, family and to the DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting injuries, falls or incidents could be delay in medical care, neglect, and potential death (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 5 of 18 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 08/22/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete depending on the situation. 7. Record review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 8. Record review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.9. Record review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 10. Record review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025. On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675925 If continuation sheet Page 6 of 18 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 08/22/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect in that: 1. CNA C neglected to notify LVN A or any licensed nurse of Resident #1's incident on 8/7/2025, that resulted in a broken distal femur. 2. The facility neglected to ensure Resident #1's pain was adequately assessed and treated for approximately 12 hours on 8/7/2025-8/8/2025, after Resident #1 reported having pain to her right knee following an incident with CNA C. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. While the IJ was removed on 8/22/2025 at 2:51pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, because all staff had not been trained on 08/22/2025. This failure placed residents at risk for neglect, mental anguish, pain and emotional distress.The Findings include:Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had a medical history of periprosthetic fracture around internal prosthetic right knee joint (a bone break that occurs around a knee replacement implant), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), gout (a painful form of inflammatory arthritis that happens when uric acid crystals build up in the joints), and age-related osteoporosis (a bone disease that makes bones weak and brittle, leading to an increased risk of fractures). Record review of Resident #1's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed Resident #1 had a BIMS of 4 which indicated Resident #1 had severe cognitive impairment. Section GG- Functional Abilities revealed Resident #1 required Supervision or touching assistance with chair/bed-to chair transfers and sit to stand.Record review of Resident #1's care plan revealed a focus initiated on 4/29/2025 [Resident#1] is at risk for acute/chronic pain r/t [related to] gout with an intervention to anticipate need for pain relief and respond immediately to any complaint. The care plan also revealed a focus initiated on 8/21/2025, [Resident #1] has a fracture of the right distal femur (the lower end of the thigh bone (femur), specifically the area just above the knee joint) related to hearing a pop during transfer and interventions initiated on 8/21/2025 revealed Anticipate and meet needs, be sure call light is within reach and respond promptly to all request for assistance, change surgical incision dressing as per order and PRN(as needed), follow weight bearing orders per MD order, reposition as necessary to prevent skin breakdown, therapy evaluation and treatment per orders. Record review of Resident #1's document titled Physical Therapy Treatment Encounter Note(s) dated 8/7/2025 at 4:00pm, revealed Pt (patient) STS (sit to stand) and stand pivot with CGA ( Contact Guard Assist, describes a level of assistance where a therapist or caregiver has their hands on the patient to provide physical support and balance for tasks like walking or standing, even though the patient performs most of the activity) /[NAME] (minimum assistance)Record review of Resident #1's progress note dated 8/8/25 at 7:10AM, revealed X ray to the Right Knee to R/O Dislocation. pt Stated she heard a loud pop when transferring to bed last HS, she c/o to this nurse this morning that she was in pain, and she couldn't move her leg. This nurse medicated pt for pain level 10 and notified NP. requested X ray to R/O Dislocation of the RT knee. STAT signed by RN H. Progress note dated 8/8/25 at 10:56 AM revealed Per [MD] sent pt to [hospital] to get tx and evaluate for the rt knee fx signed by RN H. Record review of Resident #1's radiology report dated 8/8/2025 at 10:02AM, revealed Impressions: 1. Osteoporosis 2. The knee arthroplasty is aligned (the specific way the new knee joint components are positioned during surgery to restore function and balance) 3. The acute distal femoral metaphyseal [the wider portion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 7 of 18 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 08/22/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of a bone] fracture is visualized with posterior displacement (distal femoral metaphyseal fracture with posterior displacement is a serious injury to the thigh bone, just above the knee. Posterior displacement means the broken end of the thigh bone has shifted backward towards the back of the knee). Record review of Resident #1's physician orders revealed Tramadol 50mg. Give 50mg by mouth two times a day for pain 0800 and 1800 [8am and 6pm] with a start date of 4/28/2025 and end date of 8/8/2025. Resident #1's physician orders also revealed Gabapentin Capsule 100mg. Give 1 capsule by mouth two times a day related to pain. 7am and 15 [3pm] with a start date of 4/29/2025 and an end date of 8/8/2025. Physician order to monitor and assess level of pain using the 0-10 scale, 0=no pain, 1-2 mild pain, 4-6 moderate pain, 7-10- severe pain with start date of 4/28/2025 per shift.Record review of Resident #1's medication administration record revealed Gabapentin was administer[PH1] [CO2] on 8/7/2025 at approximately 1500 [3pm] and 8/8/2025 at approximately 7AM. The document also revealed Tramadol 50mg was administered 8/7/2025 at 17:28 (5:28pm) and again on 8/8/2025 at 9:46AM. The document did not reveal any other pain medication administered between 8/7/2025 9pm and 8/8/2025 9AM. The document revealed an assessment of pain was completed on 8/8/2025 at 1:38AM by LVN A, and a score of 0 indicating no pain was documented. Record review of Resident #1's hospital records revealed Date of admission: [DATE]; History of present illness: presents to [hospital] ED (emergency department) via EMS (emergency medical services) with complaints of right knee pain. Patient states that she fell yesterday when trying to transfer to the shower with the assistance of nurse aide and lost balance causing her to fall and hit the right side of her body. Patient denies pain to her remaining extremities. Denies hitting her head. Denies blood thinner use. Denies blurry vision or headache. Denies numbness or tingling. States that her functional status prior to injury was ambulatory with assistive device and occasional wheelchair use. Diagnostic Studies: [X-ray] acute distal femoral fracture.Date: 08/08/25, open reduction internal fixation of right periprosthetic supracondylar distal femur fracture (surgical repair of distal femur).During an interview with Resident #1's family member on 8/20/2025 at 7:10 pm, she stated Resident #1 had a fall on 8/7/2025 and had sustained a broken distal femur. She stated Resident #1 had called her on 8/8/2025 about the fall and that Resident #1 told her during the night a CNA was attempting to take her to the shower and during the transfer Resident #1 fell and her knee popped. Resident #1's family member stated she was not sure if the CNA was unable to handle Resident #1's weight or why they had only sent one person to assist Resident #1 but she was upset that the incident had happened on 8/7/2025 but nothing was done until 8/8/2025. She stated she was notified by the facility around 10AM on 8/8/25 that Resident #1 had notified the morning nurse of her knee popping and they obtained an x-ray showing a fracture to the right knee. She stated Resident #1 was sent out to the hospital where she had to have surgery to the right knee to repair the fracture. She stated she did speak to the morning nurse and she was made to feel as though it was Resident #1's fault because she was told this occurred due to Resident #1 attempting to self-transfer. She stated she wanted to know what had actually happened because she did not believe Resident #1 would be lying about having a fall. She stated Resident #1 also complained of being in pain and not having received any pain medication through the night to alleviate the pain in her knee. During an interview with Resident #1 on 8/20/2025 at 8:45 PM, she stated she did not remember when the incident occurred or with who, but she remembers it was at night and the CNA had come to help her into her wheelchair. She stated she is not sure what happened, but the CNA was unable to hold her weight and they both fell together onto the floor. She stated she heard her knee pop after they fell. She stated the CNA went to get help and returned with another CNA and between both of them they assisted her back into bed. She stated she does not remember anyone checking on her through the night and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 8 of 18 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 08/22/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few complained of her right knee hurting. Resident #1 stated she did not want any of the CNAs to get in trouble. She stated she told them her knee had popped and the morning nurse gave her pain medication, called the doctor and they sent her to the hospital. She stated at the hospital she had surgery on her right knee. She stated she really cares for the staff and did not want anyone to get in trouble and understood it was an accident. During a second interview with Resident #1 on 8/21/2025 at 1:20pm, she stated the night of the incident, she had been in pain the entire night and does not remember getting any pain medication. She stated the incident made her feel bad and in pain. She stated prior to the incident she had no issues with the staff and since she has been back, all her needs are being met. During an interview with LVN A on 8/20/2025 at 9:29 pm, she stated she was working 8/7/2025 and worked with Resident #1. She stated on 8/7/2025, no report of an injury or fall had been reported to her by anyone. She stated the CNAs were usually really good about reporting any minor event or any falls. She stated if she knew someone had a fall, she would go assess and notify the physician and family. She stated she does remember checking in on Resident #1 during the night of 8/7/2025 but does not remember giving her any pain medication. She stated she does not remember who called her on 8/8/2025 but they asked if Resident #1 had any injuries or falls during the night shift, and she stated she was not aware of any events for that night. She stated the week of 8/11/2025, she had heard from CNA K, that CNA C had mentioned falling with Resident #1 prior to her going to the hospital. She stated she did not report that to the DON or ADM because Resident #1 was already at the hospital, and she believed it had already been addressed. During an interview with CNA B on 8/20/2025 at 9:42AM, she stated she was working on 8/7/2025 with LVN A. She stated she usually worked[PH3] [CO4] with Resident #1. She stated on 8/7/2025 she did report that Resident #1 mentioned having a fall, to LVN A. She stated LVN A said no one had mentioned a fall to her. She stated she also mentioned to LVN A that Resident #1's knee was hurting. CNA B stated she did check on Resident #1 through the night and she complained about her knee and Resident #1 stated something feels wrong. CNA B stated Resident #1 did not detail how she fell only that her knee hurt. CNA B stated she did see LVN A go into Resident #1's room but did not know for what. CNA B stated she never went into Resident #1's room to assist her from any fall or assist her back into bed. CNA B stated she did hear from CNA K that Resident #1 had a fall with another CNA, but did not know what CNA. She stated she heard this the week after Resident #1 had been sent to the hospital. She stated she did not report that because she believed it had been addressed already. She stated she had been trained on reporting falls and accidents to her nurse. She stated she did let LVN A know about Resident #1 stating she had a fall.During an interview with the ADM on 8/20/2025 at 10:20pm, he stated no staff member had reported a fall with Resident #1 on 8/7 or 8/8. He stated on 8/8/2025 he learned of Resident #1's fracture and he spoke to Resident #1 himself. He stated at that time, Resident #1 told him, she had attempted to self-transfer into her wheelchair and heard her knee pop and sat back down in bed. He stated he did ask the night staff from 8/7/2025 if there had been any incidents or injuries with Resident #1 and no one reported any falls or injuries. He stated this was his first time learning of a potential fall. He stated if the CNAs working that night was aware Resident #1 had any form of change in condition, injury or had an incident, it should have been reported to the nurse and addressed that night with the physician and notified family. He stated at the time of the incident, there was no DON at the facility. He stated the current DON began his role on 8/15/2025. During an interview with CNA C on 8/21/2025 at 8:48AM, she stated she had been working at the facility for the past two months and she was responsible for showers. She stated on 8/7/2025, she was assisting Resident #1 from the bed to the wheelchair to take her for her shower at approximate 9pm. She stated Resident #1 is a minimal assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 9 of 18 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 08/22/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transfer and usually does very well pivoting from bed to her wheelchair. She stated she noticed Resident #1 appeared to be struggling so she got behind her and tried to hold her, but she heard Resident #1's knee pop. She stated she pulled Resident #1 towards her, and they both slid down to the floor together. She stated after they were both on the floor, Resident #1 was complaining about her right knee hurting. She stated she had been trained not to move residents after a fall and had gone to look for a nurse. She stated she was unable to find a nurse, and Resident #1 pushed her call light. She stated Resident #1 wanted to get back in to bed. She stated she went and grabbed CNA B to help her get Resident #1 back in bed and they both assisted Resident #1 back to her bed. She stated her shift ended at 10pm and she went home. She stated she did not see any nurses on her way out and did not report the incident to anyone except CNA B. She stated she was trained to report these incidents so the residents can have the proper assessments. She stated, I feel like I could have done something different in this case, I would have tried to find a different nurse on a different hallway. CNA C stated she was not aware Resident #1 had been sent to the hospital for a broken femur and required surgery. During an interview with CNA K on 8/21/2025 at 9:09AM, she stated she heard about Resident #1 having a fall from report. She stated she did not remember who told her but she was making sure to pass the information down during report. She stated she does not usually work the hall Resident #1 is on, but that she had worked with her in the past. She stated when she asked where she was, that is when she was told Resident #1 had a fall and was at the hospital. She stated she was here on 8/7/2025 but did not know of any fall that day but if a fall had occurred it should have been reported as soon as possible. She stated she was not present for a fall, and did not know any details about the fall, only that Resident #1 had a fall. During an interview with the MD on 8/22/2025 at 11:00AM, he stated he had been made aware of Resident #1's knee hurting after a bed to wheelchair transfer [8/8/2025]. He stated from his understanding Resident #1 was transferring and heard a pop and was sat down in the wheelchair. He stated he had not been aware the incident occurred the night before and staff should have notified him that night [8/7/2025]. He stated he expects staff to notify him of any incidents or injuries as soon as possible. The MD stated if any resident is experiencing pain, he expects the nursing staff to provide what is ordered for pain and if those orders do not alleviate the pain, to call for further orders. Record review of facility policy title Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment original date: 11/2017 revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Record review of facility policy titled Change in Condition, last revised 4/2025 revealed .1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identity need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using telephone or similar process to obtain new orders or interventions. Record review of facility policy titled Rounds undated, revealed; It is the policy of this facility to ensure the safety ad comfort of the resident and to assist in continuity of care and to identify potential change in condition. 1. Resident will be checked by the certified nursing assistants during rounds. 2. Observe resident for privacy, dignity and safety. 3. Note positioning of the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 10 of 18 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 08/22/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and comfort level.The ADM and DON were notified an IJ situation was identified due to the above failures on 08/21/25 at 2:51 PM and the IJ template was provided. The following Plan of Removal was accepted on 8/21/25 at 6:13 PM: Plan of Removal 8/21/25Per the information provided in the IJ template given on 8/21/25 at 2:51. CNA C failed to properly notify the charge nurse, and/or the MD that resident #1 heard a pop and had to be guided to the floor on 8/7 /25.1. The Medical Director was notified of IJ on 8/21/25 by the Executive Director [ADM].2. Head to toe Assessment completed by DON on Resident #1 on 8/21/25.3. Suspension of CNA C on 8/20/254. Safe survey completed on all residents on 8/21/25.5. Education completed on 8/21/25 with licensed nurses and certified nursing assistance on:a. Reporting any change of condition to the charge nurseb. Abuse and Neglect6. Quiz was completed on 8/21/2025 to the certified nursing assistants currently on shift to indicate competency. All quizzes and competencies for CNAs to be completed by 8/22/25.7. This training and competencies were completed on 8/21/25 with current staff on shift. A member of management will be at the facility at each change of shift to ensure remaining staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will not be allowed to work unless they have received their training and knowledge check.8. An ad hoc (as needed) meeting regarding items in the IJ template was completed on 8/21/25 with complete policy review. Attendees included the Medical Director, Executive Director-[facility] [ADM], Executive Director [corporate], Director of Nursing-[facility], Director of Nursing [corporate], Clinical Market Leader and Clinical Resource.9. The DON, ADON will verify staff competency with staff weekly.10. All residents with new complaints of injury or pain will be reviewed by DON, ADON or designee every week in clinical meetings to assure assessments have been completed timely.11. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance.On 08/22/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. During an interview with the MD on 8/22/2025 at 11:00AM he stated he was notified of the IJ templates, and the facility had a QAPI meeting, and they had implemented a plan of removal. He stated the facility would be implementing more training and education on abuse and neglect and on reporting any changes in condition. He stated they would continue to review through QAPI meetings for effectiveness. 2. Record review of document titled Skin Evaluation dated 8/21/2025 at 1500 [3pm] for Resident #1 revealed: Resident noted resting in bed upon enter. Skin assessment completed by this DON. Post surgical wound noted to right thigh, dressing CDI (clean, dry, intact).Full head to toe assessment completed and no other concerns or issues noted at this time, signed by DON on 8/22/2025. 3. Record review of document titled View Event revealed: For [CNA C].last day of work: 8/20/2025, first day of leave: 8/21/2025.leave type: Suspension.4. Record review revealed Safe Surveys dated 8/20/2025 had been conducted with 83 Residents in the facility. Safe Survey documents revealed all 83 residents stated yes they felt safe at the facility, and they report abuse to the administrator. They all stated yes, staff treated them with dignity and respect, and they felt their needs and concerns were reported to the appropriate parties. Record review revealed Pain evaluation in Advanced Dementia assessments were completed for 31 Residents in the facility on 8/20/2025. All 31 Resident assessments revealed breathing normal, no negative vocalization, facial expressions; smiling or inexpressive, body language; relaxed and consolability; no need to console. 5. Record review of facility document titled Inservice Title: Reporting Allegations and Suspicions of abuse or neglect and change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed [ADM] is the facilities abuse and neglect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 11 of 18 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 08/22/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete coordinator. All suspicions and allegations of abuse or neglect must be reported directly to the abuse coordinator immediately. If anyone reports suspicious or witness abuse of any kind, it must be reported directly [ADM] per our policy.We must do everything we can to protect our residents. All allegations will be investigated per facility and state policy. 6. Record review of facility quiz titled Assessing and Reporting pain dated 8/21/-8/22 revealed 71 staff members had completed the quiz. The quiz revealed the following questions were asked to staff Give me an example of when you would assess for and report pain? Who would you report pain to? What are the non-verbal signs of pain? How would you communicate pain to the nurse?. Further review of the documents revealed staff stated they would assess for pain if a resident expressed pain at any time, or if they had facial or physical signs of pain. The staff stated they would report pain to the charge nurse and provider. The staff stated non verbal signs of pain would be frequent moaning, facial expressions, and elevated vital signs. The staff stated they would communicate the residents pain verbally to the nurse or provider and detail where the pain was expressed to be. 7. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L, M, N, P, Q, R, S, T, GVN F, CMA G, LVN E, I, J, O, and RN H revealed all staff members had been trained on reporting abuse and neglect. All staff members stated they would report abuse and neglect to their ADM immediately. All staff members stated they would report any falls, injuries or incidents to the charge nurse, physician, and DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting abuse or neglect could be decrease in quality of life for the residents, decrease in care, and emotional anguish. 8. Record review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 9. Record review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.10. Record review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 11. Record review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025.On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675925 If continuation sheet Page 12 of 18 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 08/22/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for neglect.1. The facility failed to ensure staff followed the abuse policy by not preventing neglect for Resident #1 on 8/7/2025 when CNA C failed to notify a licensed nurse of an incident that resulted in a broken distal femur for Resident #1. 2. The facility failed to ensure staff followed the abuse policy by not preventing neglect for Resident #1 on 8/7/2025 when staff failed to adequately assess and treat Resident #1's report of pain, for approximately 12 hours, to her right knee following an incident with CNA C. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. While the IJ was removed on 8/22/2025 at 2:51pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, because all staff had not been trained on 08/22/2025. These failures could place residents at risk for injury and neglect. The Findings include:Record review of facility policy title Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment original date: 11/2017 revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Record review of facility policy titled Change in Condition, last revised 4/2025 revealed .1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identity need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using telephone or similar process to obtain new orders or interventions. Record review of facility policy titled Rounds undated, revealed; It is the policy of this facility to ensure the safety ad comfort of the resident and to assist in continuity of care and to identify potential change in condition. 1. Resident will be checked by the certified nursing assistants during rounds. 2. Observe resident for privacy, dignity and safety. 3. Note positioning of the resident and comfort level. Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had a medical history of periprosthetic fracture around internal prosthetic right knee joint (a bone break that occurs around a knee replacement implant), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), gout (a painful form of inflammatory arthritis that happens when uric acid crystals build up in the joints), and age-related osteoporosis (a bone disease that makes bones weak and brittle, leading to an increased risk of fractures). Record review of Resident #1's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed Resident #1 had a BIMS of 4 which indicated Resident #1 had severe cognitive impairment Section GG- Functional Abilities revealed Resident #1 required Supervision or touching assistance with chair/bed-to chair transfers and sit to stand.Record review of Resident #1's care plan revealed a focus initiated on 4/29/2025 [Resident#1] is at risk for acute/chronic pain r/t [related to] gout with an intervention to anticipate need for pain relief and respond immediately to any complaint. The care plan also revealed a focus initiated on 8/21/2025, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 13 of 18 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 08/22/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [Resident #1] has a fracture of the right distal femur (the lower end of the thigh bone (femur), specifically the area just above the knee joint) related to hearing a pop during transfer and interventions initiated on 8/21/2025 revealed Anticipate and meet needs, be sure call light is within reach and respond promptly to all request for assistance, change surgical incision dressing as per order and PRN(as needed), follow weight bearing orders per MD order, reposition as necessary to prevent skin breakdown, therapy evaluation and treatment per orders. Record review of Resident #1's document titled Physical Therapy Treatment Encounter Note(s) dated 8/7/2025 at 4:00pm, revealed Pt (patient) STS (sit to stand) and stand pivot with CGA ( Contact Guard Assist, describes a level of assistance where a therapist or caregiver has their hands on the patient to provide physical support and balance for tasks like walking or standing, even though the patient performs most of the activity) /[NAME] (minimum assistance)Record review of Resident #1's progress note dated 8/8/25 at 7:10AM revealed X ray to the Right Knee to R/O Dislocation. pt Stated she heard a loud pop when transferring to bed last HS, she c/o to this nurse this morning that she was in pain, and she couldn't move her leg. This nurse medicated pt for pain level 10 and notified NP. requested X ray to R/O Dislocation of the RT knee. STAT signed by RN H. Progress note dated 8/8/25 at 10:56 AM revealed Per [MD] sent pt to [hospital] to get tx and evaluate for the rt knee fx signed by RN H. Record review of Resident #1's radiology report dated 8/8/2025 10:02AM revealed Impressions: 1. Osteoporosis 2. The knee arthroplasty is aligned (the specific way the new knee joint components are positioned during surgery to restore function and balance) 3. The acute distal femoral metaphyseal [the wider portion of a bone] fracture is visualized with posterior displacement (distal femoral metaphyseal fracture with posterior displacement is a serious injury to the thigh bone, just above the knee. Posterior displacement means the broken end of the thigh bone has shifted backward towards the back of the knee). Record rview of Resident #1's physician orders revealed Tramadol 50mg. Give 50mg by mouth two times a day for pain 0800 and 1800 [8AMand 6pm] with a start date of 4/28/2025 and end date of 8/8/2025. Resident #1's physician orders also revealed Gabapentin Capsule 100mg. Give 1 capsule by mouth two times a day related to pain. 7AM and 15 [3pm] with a start date of 4/29/2025 and an end date of 8/8/2025. Physician order to monitor and assess level of pain using the 0-10 scale, 0=no pain, 1-2 mild pain, 4-6 moderate pain, 7-10- severe pain with start date of 4/28/2025 per shift.Record review of Resident #1's medication administration record revealed Gabapentin was administer on 8/7/2025 at approximately 1500 [3pm] and 8/8/2025 at approximately 7AM. The document also revealed Tramadol 50mg was administered 8/7/2025 at 17:28pm(5;28pm) and again on 8/8/2025 at 9:46AM. The document did not reveal any other pain medication administered between 8/7/2025 9pm and 8/8/2025 9AM. The document revealed an assessment of pain was completed on 8/8/2025 at 1:38am by LVN A, and a score of 0 indicating no pain was documented. Record review of Resident #1's hospital records revealed Date of admission: [DATE]; History of present illness: presents to [hospital] ED (emergency department) via EMS (emergency medical services) with complaints of right knee pain. Patient states that she fell yesterday when trying to transfer to the shower with the assistance of nurse aide and lost balance causing her to fall and hit the right side of her body. Patient denies pain to her remaining extremities. Denies hitting her head. Denies blood thinner use. Denies blurry vision or headache. Denies numbness or tingling. States that her functional status prior to injury was ambulatory with assistive device and occasional wheelchair use. Diagnostic Studies: [X-ray] acute distal femoral fracture.Date: 08/08/25, open reduction internal fixation of right periprosthetic supracondylar distal femur fracture (surgical repair of distal femur).During an interview with Resident #1's family member on 8/20/2025 at 7:10pm, she stated Resident #1 had a fall on 8/7/2025 and had sustained a broken distal femur. She stated Resident #1 had called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 14 of 18 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 08/22/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few her on 8/8/2025 about the fall and that Resident #1 told her during the night a CNA was attempting to take her to the shower and during the transfer Resident #1 fell and her knee popped. Resident #1's family member stated she was not sure if the CNA was unable to handle Resident #1's weight or why they had only sent one person to assist Resident #1 but she was upset that the incident had happened on 8/7/2025 but nothing was done until 8/8/2025. She stated she was notified by the facility around 10AM on 8/8/25 that Resident #1 had notified the morning nurse of her knee popping and they obtained an x-ray showing a fracture to the right knee. She stated Resident #1 was sent out to the hospital where she had to have surgery to the right knee to repair the fracture. She stated she did speak to the morning nurse and she was made to feel as though it was Resident #1's fault because she was told this occurred due to Resident #1 attempting to self-transfer. She stated she wanted to know what had actually happened because she did not believe Resident #1 would be lying about having a fall. She stated Resident #1 also complained of being in pain and not having received any pain medication through the night to alleviate the pain in her knee. During an interview with Resident #1 on 8/20/2025 at 8:45PM, she stated she did not remember when the incident occurred or with who, but she remembers it was at night and the CNA had come to help her into her wheelchair. She stated she is not sure what happened, but the CNA was unable to hold her weight and they both fell together onto the floor. She stated she heard her knee pop after they fell. She stated the CNA went to get help and returned with another CNA and between both of them they assisted her back into bed. She stated she does not remember anyone checking on her through the night and she complained of her right knee hurting. Resident #1 stated she did not want any of the CNAs to get in trouble. She stated she told them her knee had popped and the morning nurse gave her pain medication, called the doctor and they sent her to the hospital. She stated at the hospital she had surgery on her right knee. She stated she really cares for the staff and did not want anyone to get in trouble and understood it was an accident. During a second interview with Resident #1 on 8/21/2025 at 1:20pm, she stated the night of the incident, she had been in pain the entire night and does not remember getting any pain medication. She stated the incident made her feel bad and in pain. She stated prior to the incident she had no issues with the staff and since she has been back, all her needs are being met. During an interview with LVN A on 8/20/2025 at 9:29pm, she stated she was working 8/7/2025 and worked with Resident #1. She stated on 8/7/2025, no report of an injury or fall had been reported to her by anyone. She stated the CNAs were usually really good about reporting any minor event or any falls. She stated if she knew someone had a fall, she would go assess and notify the physician and family. She stated she does remember checking in on Resident #1 during the night of 8/7/2025 but does not remember giving her any pain medication. She stated she does not remember who called her on 8/8/2025 but they asked if Resident #1 had any injuries or falls during the night shift, and she stated she was not aware of any events for that night. She stated the week of 8/11/2025, she had heard from CNA K, that CNA C had mentioned falling with Resident #1 prior to her going to the hospital. She stated she did not report that to the DON or ADM because Resident #1 was already at the hospital, and she believed it had already been addressed. During an interview with CNA B on 8/20/2025 at 9:42AM, she stated she was working on 8/7/2025 with LVN A. She stated she usually works with Resident #1. She stated on 8/7/2025 she did report that Resident #1 mentioned having a fall, to LVN A. She stated LVN A said no one had mentioned a fall to her. She stated she also mentioned to LVN A that Resident #1's knee was hurting. CNA B stated she did check on Resident #1 through the night and she complained about her knee and Resident #1 stated something feels wrong. CNA B stated Resident #1 did not detail how she fell only that her knee hurt. CNA B stated she did see LVN A go into Resident #1's room but did not know for what. CNA B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 15 of 18 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 08/22/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated she never went into Resident #1's room to assist her from any fall or assist her back into bed. CNA B stated she did hear from CNA K that Resident #1 had a fall with another CNA, but did not know what CNA. She stated she heard this the week after Resident #1 had been sent to the hospital. She stated she did not report that because she believed it had been addressed already. She stated she had been trained on reporting falls and accidents to her nurse. She stated she did let LVN A know about Resident #1 stating she had a fall.During an interview with the ADM on 8/20/2025 at 10:20pm, he stated no staff member had reported a fall with Resident #1 on 8/7 or 8/8. He stated on 8/8/2025 he learned of Resident #1's fracture and he spoke to Resident #1 himself. He stated at that time, Resident #1 told him, she had attempted to self-transfer into her wheelchair and heard her knee pop and sat back down in bed. He stated he did ask the night staff from 8/7/2025 if there had been any incidents or injuries with Resident #1 and no one reported any falls or injuries. He stated this was his first time learning of a potential fall. He stated if the CNAs working that night were aware Resident #1 had any form of change in condition, injury or had an incident, it should have been reported to the nurse and addressed that night with the physician and notified family. He stated at the time of the incident, there was no DON at the facility. He stated the current DON began his role on 8/15/2025. During an interview with CNA C on 8/21/2025 at 8:48AM, she stated she had been working at the facility for the past two months and she was responsible for showers. She stated on 8/7/2025, she was assisting Resident #1 from the bed to the wheelchair to take her for her shower at approximate 9pm. She stated Resident #1 is a minimum assistance transfer and usually does very well pivoting from bed to her wheelchair. She stated she noticed Resident #1 appeared to be struggling so she got behind her and tried to hold her, but she heard Resident #1's knee pop. She stated she pulled Resident #1 towards her, and they both slid down to the floor together. She stated after they were both on the floor, Resident #1 was complaining about her right knee hurting. She stated she had been trained not to move residents after a fall and had gone to look for a nurse. She stated she was unable to find a nurse, and Resident #1 pushed her call light. She stated Resident #1 wanted to get back in to bed. She stated she went and grabbed CNA B to help her get Resident #1 back in bed and they both assisted Resident #1 back to her bed. She stated her shift ended at 10pm and she went home. She stated she did not see any nurses on her way out and did not report the incident to anyone except CNA B. She stated she was trained to report these incidents so the residents can have the proper assessments. She stated, I feel like I could have done something different in this case, I would have tried to find a different nurse on a different hallway. CNA C stated she was not aware Resident #1 had been sent to the hospital for a broken femur and required surgery. During an interview with CNA K on 8/21/2025 at 9:09AM, she stated she had heard about Resident #1 having a fall from report. She stated she did not remember who told her but she was making sure to pass the information down during report. She stated she does not usually work the hall Resident #1 is on, but that she had worked with her in the past. She stated when she asked where she was, that is when she was told Resident #1 had a fall and was at the hospital. She stated she was here on 8/7/2025 but did not know of any fall that day but if a fall had occurred it should have been reported as soon as possible. She stated she was not present for a fall, and did not know any details about the fall, only that Resident #1 had a fall. During an interview with the MD on 8/22/2025 at 11:00AM, he stated he had been made aware of Resident #1's knee hurting after a bed to wheelchair transfer [8/8/2025]. He stated from his understanding Resident #1 was transferring and heard a pop and was sat down in the wheelchair. He stated he had not been aware the incident occurred the night before and staff should have notified him that night [8/7/2025]. He stated he expects staff to notify him of any incidents or injuries as soon as possible. The MD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 16 of 18 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 08/22/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated if any resident is experiencing pain, he expects the nursing staff to provide what is ordered for pain and if those orders do not alleviate the pain, to call for further orders. The ADM and DON were notified an IJ situation was identified due to the above failures on 08/21/25 at 2:51 PM and the IJ template was provided. The following Plan of Removal was accepted on 8/21/25 at 6:13 PM: Plan of Removal 8/21/25Per the information provided in the IJ template given on 8/21/25 at 2:51. CNA C failed to properly notify the charge nurse, and/or the MD that resident #1 heard a pop and had to be guided to the floor on 8/7 /25.1. The Medical Director was notified of IJ on 8/21/25 by the Executive Director [ADM].2. Head to toe Assessment completed by DON on Resident #1 on 8/21/25.3. Suspension of CNA C on 8/20/254. Safe survey completed on all residents on 8/21/25.5. Education completed on 8/21/25 with licensed nurses and certified nursing assistance on:a. Reporting any change of condition to the charge nurseb. Abuse and Neglect6. Quiz was completed on 8/21/2025 to the certified nursing assistants currently on shift to indicate competency. All quizzes and competencies for CNAs to be completed by 8/22/25.7. This training and competencies were completed on 8/21/25 with current staff on shift. A member of management will be at the facility at each change of shift to ensure remaining staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will not be allowed to work unless they have received their training and knowledge check.8. An ad hoc (as needed) meeting regarding items in the IJ template was completed on 8/21/25 with complete policy review. Attendees included the Medical Director, Executive Director-[facility] [ADM], Executive Director [corporate], Director of Nursing-[facility], Director of Nursing [corporate], Clinical Market Leader and Clinical Resource.9. The DON, ADON will verify staff competency with staff weekly.10. All residents with new complaints of injury or pain will be reviewed by DON, ADON or designee every week in clinical meetings to assure assessments have been completed timely.11. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance.On 08/22/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. During an interview with the MD on 8/22/2025 at 11:00AM he stated he was notified of the IJ templates, and the facility had a QAPI meeting, and they had implemented a plan of removal. He stated the facility would be implementing more training and education on abuse and neglect and on reporting any changes in condition. He stated they would continue to review through QAPI meetings for effectiveness. 2. Record review of document tiled Skin Evaluation dated 8/21/2025 1500 [3pm] for Resident #1 revealed: Resident noted resting in bed upon enter. Skin assessment completed by this DON. Post surgical wound noted to right thigh, dressing CDI (clean, dry, intact).Full head to toe assessment completed and no other concerns or issues noted at this time, signed by DON on 8/22/2025. 3. Record review of document titled View Event revealed: For [CNA C].last day of work: 8/20/2025, first day of leave: 8/21/2025.leave type: Suspension.4. Record Review revealed Safe Surveys dated 8/20/2025 had been conducted with 83 Residents in the facility. Safe Survey documents revealed all 83 residents stated yes they felt safe at the facility, and they report abuse to the administrator. They all stated yes, staff treated them with dignity and respect, and they felt their needs and concerns were reported to the appropriate parties. Record review revealed Pain evaluation in Advanced Dementia assessments were completed for 31 Residents in the facility on 8/20/2025. All 31 Resident assessments revealed breathing normal, no negative vocalization, facial expressions; smiling or inexpressive, body language; relaxed and consolability; no need to console. 5. Record review of facility document titled Inservice Title: Reporting Allegations and Suspicions of abuse or neglect and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675925 If continuation sheet Page 17 of 18 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 08/22/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed [ADM] is the facilities abuse and neglect coordinator. All suspicions and allegations of abuse or neglect must be reported directly to the abuse coordinator immediately. If anyone reports suspicious or witness abuse of any kind, it must be reported directly [ADM] per our policy.We must do everything we can to protect our residents. All allegations will be investigated per facility and state policy. 6. Record review of facility quiz titled Assessing and Reporting pain dated 8/21/-8/22 revealed 71 staff members had completed the quiz. The quiz revealed the following questions were asked to staff Give me an example of when you would assess for and report pain? Who would you report pain to? What are the non-verbal signs of pain? How would you communicate pain to the nurse?. Further review of the documents revealed staff stated they would assess for pain if a resident expressed pain at any time, or if they had facial or physical signs of pain. The staff stated they would report pain to the charge nurse and provider. The staff stated non verbal signs of pain would be frequent moaning, facial expressions, and elevated vital signs. The staff stated they would communicate the residents pain verbally to the nurse or provider and detail where the pain was expressed to be. 7. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L ,M ,N ,P, Q, R, S ,T, GVN F, CMA G, LVN E, I,J, O, and RN H revealed all staff members had been trained on reporting abuse and neglect. All staff members stated they would report abuse and neglect to their ADM immediately. All staff members stated they would report any falls, injuries or incidents to the charge nurse, physician, and DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting abuse or neglect could be decrease in quality of life for the residents, decrease in care, and emotional anguish. 8. Record Review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 9. Record Review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.10. Record Review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 11. Record Review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025.On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675925 If continuation sheet Page 18 of 18