Inspection·October 27, 2023

F 0677 notation related to a potential shower or bath on 10/07/2023 or on 10/17/2023. Level of Harm - Minimal harm or potential for actual harm Interview on 10/25/2023 at 3:45 PM, Resident #5 stated he had not been getting showered recently and only just got it today. Resident #5 stated he did not have to ask for showers and is given them on a recurring basis. Residents Affected - Some 2. Record review of Resident #31's admission Record dated 10/28/23 documented a [AGE] year-old male initially admitted [DATE] with his most recent admission on [DATE]. His diagnoses included schizophrenia, Type 2 diabetes mellitus, muscle weakness, repeated falls, anxiety disorder, and drug induced subacute dyskinesia (uncontrolled, involuntary muscle movement). Record review of Resident #31's Quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. Section GG0130 - Self-Care - was marked as 01 for Shower/bathe self: Dependent Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #31's most recent Care Plan indicated a Focus with revision date of 07/26/23 of Living Self Care Performance Deficit due to weakness, impaired memory. One of the interventions indicated Total assist x 1 assist with showers - Date initiated 02/15/19. Record review of Resident #31's POC Response History for October 2023 revealed resident was scheduled for bathing on Tuesday, Thursday and Saturday but only received 2 out of the 11 scheduled showers from 10/01/23 through 10/26/23. During an interview with Resident #31 on 10/25/23 at 9:29 AM, resident indicated he wants help to brush his teeth but doesn't always get it. Resident #31 stated he has to wait for someone to help him with all ADLs but doesn't always get the help he needs. During an interview with Resident #31 on 10/26/23, resident stated I finally got a shave - I didn't get one for a week. On 10/26/23 at 01:30 pm, an interview with CNA B revealed that resident gets his showers every Tuesday-Thursday-Saturday. He also brushes his own teeth daily and is able to do so from sitting at the sink in his WC. When surveyor pointed out that only 1 day was documented in PCC for showers, she stated, I don't have time to document due to the number of people I have to care for. She stated, Resident #31 always wants to be clean so he gets a shower at least 3 times per week. CNA B also stated that Resident #31 was incontinent so he uses a brief - if he can tell them in time, they will put him on toilet but its often too late. Interview on 10/26/2023 at 8:54 AM, the ADM stated the recently hired DON instituted a policy for staff to not complete paper shower logs and instead to only document in the EHR. The ADM stated the DON had been hired in the last several weeks and was not available for interview as the DON was on vacation. Interview on 10/26/23 at 12:25 PM, LVN A stated she worked on 10/07/2023 and on 10/17/2023 and stated on the days that she worked, Resident #5 is showered by her, or by assistance of her. LVN A stated when a nurse assists a CNA in showering, either can document in the EHR however recalled that on 10/07/2023 and on 10/17/2023 she had forgotten to document the completed shower for Resident #5. LVN A stated the risk associated with failing to document ADL assistance such as showers is that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 2 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0677 residents may not receive the ADL assistance as planned. Level of Harm - Minimal harm or potential for actual harm Interview on 10/26/2023 at 12:59 PM, the Corporate Compliance Nurse stated she did not see a documented indication of a shower of Resident #5 on 10/07/2023 or on 10/17/2023. The Corporate Compliance Nurse stated staff are expected to document all ADL tasks in the EHR as that ensures ADL care was completed. The Corporate Compliance Nurse stated due to the lack of documentation, that implies the task did not occur. Residents Affected - Some Interview on 10/26/2023 at 1:10 PM, the ADM stated it was her expectation that all ADL care be documented in the EHR under the POC or at minimum the progress notes to reflect an ADL task was completed such as showering. The ADM stated the risk posed by failing to document the ADL task was that the ADL might not be completed for the residents. A facility policy on showers or ADLs was presented by facility but it did not indicate how, when or where documentation for ADLs should be recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 3 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #27) reviewed for dialysis in that: Residents Affected - Few The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #27. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #27's face sheet, dated 10/26/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with, hyperlipidemia (elevated cholesterol), cognitive communication deficit, end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), type 2 diabetes mellites, and dependence on renal dialysis. Record review of Resident #27's most recent admission MDS assessment, dated 09/14/23, revealed the resident was severely cognitively impaired for daily decision-making skills and required dialysis treatments. Record review of Resident #27's comprehensive care plan, revision date 09/30/23 revealed the resident needs hemodialysis related to renal failure initiated on 06/13/22 with interventions Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Record review of Resident #27's Order Summary Report, dated 10/26/23 revealed the following: -Dialysis provided Monday, Wednesday, and Friday with order date 06/08/22 and no end date. Record review of Resident #27's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for 10/02/23, 10/04/23, 10/06/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/20/23, 10/23/23, 10/25/23. The Post-Dialysis section of the Dialysis Communication form for the aforementioned dates were blank. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain scale rating, assessment of the AV site (area accessed for dialysis treatment), a nurse's signature, date and time. Record review of document titled Blood pressure summary, dated 10/26/23, revealed the last facility documentation for a blood pressure were: -No recordings for 10/25/23 -No recordings for 10/23/23 -No recordings for 10/20/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 4 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0698 -No recording for 10/18/23 Level of Harm - Minimal harm or potential for actual harm -No recordings for 10/16/23 -No recordings for 10/13/23 Residents Affected - Few -No recordings of evening blood pressure/return from dialysis on 10/11/23 - 10/11/23 (Wednesday) at 8:24 a.m. of 88/48 mmHg - No recordings of evening blood pressure/return from dialysis on 10/09/23 -10/09/23 (Monday) at 7:51 a.m. of 136/70 mmHg -10/06/23 (Friday) at 6:00 p.m. of 128/74 mmHg -10/06/23 (Friday) at 8:24 a.m. of 141/75 mmHg -10/04/23 (Wednesday) at 6:13 p.m. of 124/62 mmHg -10/04/23 (Wednesday) at 7:34 a.m. of 146/68 mmHg -No recordings of evening blood pressure/return from dialysis on 10/02/23 -10/02/23 (Monday) at 7:53 a.m. of 139/79 mmHg During an interview on 10/26/23 at 3:29 p.m. LVN C stated Resident #27 went to dialysis 3 days a week on Mondays, Wednesdays, and Fridays. LCN C stated the resident goes around 10 a.m. and returns around 4:30-5:00 p.m. LVN C stated she was present on shift when the resident went to dialysis and returned and she was the nurse responsible for this resident. LVN C stated she was responsible for filling out the top portion of the dialysis communication form and the dialysis center would fill out the middle portion of the form. LVN C stated she had never noticed the last portion of the communication form and did not fill it out. LVN C stated when the resident returns from dialysis she usually went straight to dinner to eat and then to bed. LVN C stated there was no opportunity to take the residents vitals after returning from dialysis but if she noticed Resident #27 was not her typical self then she would obtain vitals. LVN C stated it was necessary to obtain vitals when the resident returned from dialysis because they could have pulled too much fluid from the resident, the resident could be dehydrated, and if her levels were off, she would be worried there was an issue with her port. LVN C stated she always filled out the beginning portion of the paperwork and sent it with CNA D who transported Resident #27 to dialysis. During an interview on 10/26/23 at 3:38 p.m. CNA D stated she transports the residents to and from dialysis. CNA D stated nursing staff usually always provides her with the dialysis communication form. CNA D stated the dialysis center places the paperwork in the resident backpack and she returns to the facility with the paperwork. CNA D stated the paperwork was important to make sure how much fluid they drain from the resident before and after. CNA D stated if they did not check the vitals on return the resident could be drowning in her own fluids. During an interview on 10/26/23 at 4:39 p.m. RN E stated the form is an older form and she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 5 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sure if it was required, they fill out the portion on return. This surveyor pointed out that another resident who received dialysis at the facility had the dialysis communication forms entirely filled out. RN E later stated she read the policy for dialysis and the receiving nurse at the facility should be obtaining vitals on return. Record review of the facility's policy titled Dialysis, dated 10/2013, stated dialysis is a process used to remove fluid and waste products from the body when the kidneys are unable to do so because of impaired function or when toxins or poisons must be removed immediately to prevent permanent or life threatening damage. The purpose of dialysis are to maintain life and well-being of the patient until kidney function is restored and to remove unwanted substances from the blood if renal function does not return. Methods of therapy include hemodialysis .Hemodialysis is a process used for patients who are acutely ill and require short-term dialysis (days to weeks) or for patients with end-stage renal disease (ESRD) who require long-term therapy. A synthetic, semi-permeable membrane replaces the renal glomeruli and tubles and acts as the filer for the impaired kidneys. For patient with chronic renal failure, hemodialysis provides reasonable rehabilitation and life expectancy. However, hemodialysis does not cure or reverse renal disease and is not able to compensate for losses of the kidney's endocrine or metabolic activities. These patients must undergo dialysis treatment for the rest of their lives, usually three times a week for at least 3 to 4 hours per treatment or until they receive a successful kidney transplant. Patients are placed on chronic dialysis when they require dialysis therapy for survival and for control of uremic symptoms .Policy all facilities administering dialysis to residents will be appropriately trained and medically staffed to do so. Equipment and supplies may be the property of the physician or the facility. Facilities boarding residents who are transported to outpatient dialysis will have contracts in place with dialysis center according to standard operation practices and the preferences of the dialysis facility .Procedure .18. The resident clinical record will be documented with this information. The date and time that the resident leaves the facility will be recorded by the nurse. 19. The facility will monitor departure and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information. The date and time of the residents returned to the facility will be recorded by the facility. Event ID: Facility ID: 675938 If continuation sheet Page 6 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an irregularity noted by the pharmacist was acted upon for 3 (Residents #3, #12, & #36) of 5 residents reviewed for pharmacy review in that: 1. The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to add a maximum daily dose of acetaminophen to the routine acetaminophen prescription order for Resident #12. 2. The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to update the diagnosis for Risperdal for Resident #3. 3. The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to order an A1C lab test (test result reflects your average blood sugar level for the past two to three months) because one was not done in the past 6 months for Resident #36. This failure could place resident as risk of not having their pharmacy consultations reviewed or recommendations implemented. The finding included: 1. Record review of Resident # 12's face sheet, dated 10/27/2023, reflected a [AGE] year-old female admitted on [DATE] with a primary diagnosis of chronic kidney disease, stage 3 unspecified (a condition where the kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood.) Record review for Resident #12's MDS, dated [DATE], reflected a BIMS summary score of four, indicating a severely impacted cognition. Record review of a Medication Review Regimen, dated 05/16/2023, reflected a nursing recommendation to add a NTE three grams in twenty-four hours of acetaminophen. Record review of Resident #12's order summary, dated 10/27/2023, reflected an order for Acetaminophen 325 grams PRN every 4 hours without specificity or maximum daily allowance indicated. Interview on 10/26/2023 at 12:45 p.m., RN E stated she did not see the recommendation to add NTE three grams within twenty-four hours reflected in the physician's orders. RN E stated when nursing recommendations were received by the pharmacy, a determination would have been made whether the acetaminophen was being administered at all, and if not, the order would have been discontinued, as opposed to if it was being administered, the NTE instruction would have been added. RN E stated that due to the order having remained without the instruction, it was concluded the recommendation was not reviewed sufficiently. RN E stated the risk posed by not implementing the NTE instruction would be that the resident could be administered higher than the daily recommended dose and potentially toxify the liver. Interview on 10/26/2023 at 1:13 p.m., the ADM stated it was her expectation that pharmacist's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 7 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing recommendations be reviewed or reflected within the clinical file discerning why the recommendation was not implemented. 2. Record review of Resident # 3's face sheet, dated 10/27/2023, reflected a [AGE] year-old female admitted on [DATE] with a diagnosis which included dementia (a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn), psychotic disorder (affect brain function by altering thoughts, beliefs or perceptions) with delusions, delusional disorder (is characterized by one or more firmly held false beliefs that persist for at least 1 month), and altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain). Record review for Resident #3's MDS, dated [DATE], reflected the resident was moderately impaired for cognition. Record review of a document titled Medication Review Regimen, dated 09/16/2023, reflected a recommendation to update diagnosis/indication for Risperdal 0.025 mg for Antipsychotic is not a CMS approved diagnosis for antipsychotic medication. It needs to be more specific. Please update it to an approved, more appropriate diagnosis. No physicians signature was noted on the document. Record review of Resident #3's order summary, dated 10/27/2023, reflected an order for: -Risperdal Oral Tablet 0.25 MG (Risperidone) Give 1 tablet by mouth one time a day for ANTIPSYCHOTIC, with a start date of 10/10/23 and no end date. Interview on 10/27/2023 at 11:50 a.m., RN E stated she did not see the recommendation to update the diagnosis on the Risperdal order. RN E stated this was not a new medication and the resident had been on it prior and the diagnosis should have been updated. 3. Record review of Resident # 36's face sheet, dated 10/27/2023, reflected a [AGE] year-old female admitted on [DATE] with a diagnosis which included type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar (glucose)) and hypertensive heart disease ( a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). Record review for Resident #36's MDS, dated [DATE], reflected the resident was severely impaired for cognition. Record review of a document titled Medication Review Regimen, dated 05/29/2023, for resident #36 reflected a recommendation to order an A1C because one was not done in the past 6 months. Record review of a document titled Medication Review Regimen, dated 08/28/2023, for resident #36 reflected a recommendation to order an A1C because one was not done in the past 6 months. A provider note stated the request was erroneous because there was already an order for an A1C every 6 months. Record review of Resident #36's order summary, dated 10/27/2023, reflected an order for: -CMP (complete metabolic profile), HBAIC (hemoglobin A1C) Q (every) 6 MONTHS every day shift every 180 day(s), with a order date of 01/24/23, start date of 02/01/23, and no end date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 8 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a document titled Patient Report, dated 03/29/23, revealed a Hemoglobin A1C was collected on 03/29/23 and resulted in a level of 8.22 (high). No other A1C labs were provided for Resident #36. Interview on 10/27/2023 at 10:38 a.m., RN E stated she contacted the lab to see if they had any labs to provide an A1C. There were no labs documented in the chart since the last order on 02/01/23. Later RN E provided a lab for the date of 03/29/23 but stated they had missed the lab order for 6 months after that date. Record review of the facility's policy titled Consultant Pharmacist, dated 10/25/17, stated the facility will contract the services of pharmacists to provide consultation on all aspects of pharmaceutical services. The facility and the pharmacist will collaborate for effective consultation regarding pharmaceutical services. The pharmacist reviews and evaluates the pharmaceutical services by helping the facility identify, evaluate, and address medication issues that may affect resident care, medical care, and quality of life. Mediation Regimen Review. The Mediation Regimen Review (MRR) is an important component of the overall management and monitoring of a resident's medication regimen .6. the consult pharmacist shall provide the facility with documentation that he has reviewed each patient's drug therapy. When potential irregularities are identified, the consult pharmacist shall complete an individualized report per resident detailing the potential irregularity. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist recommendations unless warranted by a change in the resident's condition or other circumstances .10. The attending physician will review the identified irregularity and will document what, if any, action is to be taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale. 11. With the facility has not received any communication from the physician regarding the irregularity within five business days, the facility will call physician. Any new orders from the physician will be implemented. 12. The complete report will be filed in the resident's clinical record. Record review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, dated 05/07/13, stated Definitions: diabetes is a disorder in which there is relative or absolute lack of insulin. Among other things, glucose (sugar) from food cannot be taken up by the cells, which results in elevated blood sugars (hyperglycemia) and lack of energy for cellular function. There are two types of diabetes mellitus: 1. Type I (insulin dependent diabetes mellitus) the body does not produce any significant amounts of insulin. 2. type II (non insulin dependent diabetes mellitus) and type 2 diabetes (the most common form of diabetes), either the body does not produce enough insulin or the cells cannot effectively use the insulin that is available .Glucose Monitoring: 1. The management of individuals with diabetes mellitus should follow physician orders. 2. The position will order the frequency of glucose monitoring .6. Hemoglobin A1C (glycosylated hemoglobin) blood test that measures the average blood glucose over time (2 to 3 months) and therefore may be a better estimate of treatment efficacy than blood sugar readings. 7. Percentage of glycosylated hemoglobin should be less than 7% in a diabetic individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 9 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 facility reviewed for food storage sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to remove past dated items from the dry food storage. 3. The facility failed to remove past dated items from a combined resident/staff refrigerator within the medication storage room. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation and interview on 10/24/23 beginning at 10:59 AM revealed an ice maker in the kitchen with a dark grey substance built up inside the unit. The DM stated the MS came to clean the unit on a recurring basis. The DM stated she was not sure what the substance was and stated she was not previously aware of the substances' presence. The DM stated it was her expectation that the ice maker be clean and the substance reflected an unclean ice maker. The DM stated the kitchen staff were expected to only report observed signs of uncleanliness to the MS however the kitchen were not aware of the uncleanliness within the unit as that was not within their scope of practice. The DM stated she was not ware of the potential risk of the dark grey substance contaminating the ice posted to residents. Further revealed in the dry food storage was a box of fruit & grain cereal bars with a best by date of 04/17/2023. The DM stated she was not aware of the past date listed on the cereal bars and stated it was her expectation that items that are best by dated were treated the same as use by dates and were to be destroyed all the same. The DM stated she was responsible for completing audits of the dry food storage once weekly on Tuesday's however was last able to complete the audit on 10/17/2023. The DM stated she did not discover the past date on previous audits since 04/17/2023. The DM stated she was not aware of the potential risk the past dated cereal bars posed to residents. Interview on 10/24/2023 at 4:44 PM, the ADM stated it is her expectation that the ice maker remained cleaned and sanitary while providing ice to residents. The ADM stated the risk associated with having an uncleaned ice maker be a potential ice contamination and be consumed by residents. Observation on 10/25/2023 at 1:13 PM revealed the nutrition refrigerator located within the medication room containing undated and unlabeled yogurt and alcoholic beer. Additionally revealed within the nutrition refrigerator were (4) undated and unlabeled lunch bags potentially for staff use with nectar-thickened liquid and half pints of milk potentially for resident use. Further revealed within the nutrition refrigerator were (3) units of cereal bars best by dated 04/17/2023. Interview on 10/25/2023 at 1:22 PM, the ADM stated the facility staff did not have a dedicated staff fridge in the facility and stated it was her expectation that all food within resident-use refrigerators be labeled and dated. The ADM stated she was not aware of the presence of alcoholic beer in the refrigerator located within the medication room. The ADM stated any alcohol in the facility was explicitly for the purpose of resident use as many have standing physician orders that allowed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 10 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 the consumption of alcohol. The ADM stated it was her expectation that any refrigerators in the facility that are intended for residents could not be used for staff as well. The ADM stated the risk associated with not keeping resident-use refrigerators explicitly for residents would be that food acquired by staff be provided to residents and that staff may consume alcohol while providing care at the facility. Interview on 10/25/23 at 3:25 PM, the MS stated she was not aware of the dark grey substance in the ice maker within the kitchen. The MS stated her routine cleaning of the ice maker was every six months however would clean the ice maker more frequently when a service request was made by the dietary department. The MS stated she had not received a service request in the last six months from the dietary department related to the ice maker cleanliness. The MS stated the substance appeared to be slime but was not certain of the potential risk posed to residents based on slime contact with the ice. Record review of the facility nutritional policy titled Food Storage and Supplies, undated, reflected When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark by circling it so it is readily visible and noticeable . As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. Policy specific to the ice maker or the explicit use of refrigerators was not received by the facility prior to exit. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 11 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain medical records that were complete and accurate on 1 (Residents #3) of 13 residents reviewed for resident records. The facility failed to ensure Residents #3 had a consent and diagnosis for risperidone (an antipsychotic used to treat certain mental/mood disorders) filled out correctly. This failure could place residents at risk of involuntary receiving psychotropic medication and not consenting to dosage changes. Findings included: 2. Record review of Resident # 3's face sheet, dated 10/27/2023, reflected a [AGE] year-old female admitted on [DATE] with a diagnosis which included dementia (a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn), psychotic disorder (affect brain function by altering thoughts, beliefs or perceptions) with delusions, delusional disorder (is characterized by one or more firmly held false beliefs that persist for at least 1 month), and altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain). Record review for Resident #3's MDS, dated [DATE], reflected the resident was moderately impaired for cognition. Record review of Resident #3's order summary, dated 10/27/2023, reflected an active order for: -Risperdal Oral Tablet 0.25 MG (Risperidone) Give 1 tablet by mouth one time a day for ANTIPSYCHOTIC, with a start date of 10/10/23 and no end date. Record review of a document titled Medication Review Regimen, dated 09/16/2023, reflected a recommendation to update diagnosis/indication for Risperdal 0.025 mg for Antipsychotic is not a CMS approved diagnosis for antipsychotic medication. It needs to be more specific. Please update it to an approved, more appropriate diagnosis. No physicians signature was noted on the document. Record review of a document titled Nursing Summary Report, dated 09/30/23, reflected a recommendation to Psychotropic medication management. Note per charting that Dr. gave N/O on 09/12/23 to start Risperdal 0.25 mg PO QAM. Make sure proper consents are obtained and filed and continue to monitor and document any side effects and resident behavior. Risperdal also requires quarterly AIMS assessments as well as documentation of consent on form 3713. Interview on 10/27/2023 at 11:50 a.m., RN E stated she did not see the recommendation to update the diagnosis on the Risperdal order. RN E stated this was not a new medication and the resident had been on it prior and the diagnosis should have been updated. RN E provided a copy of a consent that was not uploaded to the resident electronic medical record. Record review form 3713 titled Consent for Antipsychotic or Neuroleptic Medication Treatment, dated May 2022, reflected under section 1 an area for The following course of therapy with antipsychotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 12 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete or neuroleptic medication(s) is proposed with the following medication(s), dosage and frequency: the form stated Risperdal tablet no dosage or frequency was stated on the form. The form was signed by a physician on 09/15/23 and signed by the resident representative on 09/22/23. Record review of the facility's policy titled Consultant Pharmacist, dated 10/25/17, stated the facility will contract the services of pharmacists to provide consultation on all aspects of pharmaceutical services. The facility and the pharmacist will collaborate for effective consultation regarding pharmaceutical services. The pharmacist reviews and evaluates the pharmaceutical services by helping the facility identify, evaluate, and address medication issues that may affect resident care, medical care, and quality of life. Mediation Regimen Review. The Mediation Regimen Review (MRR) is an important component of the overall management and monitoring of a resident's medication regimen .6. the consult pharmacist shall provide the facility with documentation that he has reviewed each patient's drug therapy. When potential irregularities are identified, the consult pharmacist shall complete an individualized report per resident detailing the potential irregularity. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist recommendations unless warranted by a change in the resident's condition or other circumstances .10. The attending physician will review the identified irregularity and will document what, if any, action is to be taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale .12. The completed report will be filed in the resident's clinical record. 13. Any irregularities that do not require a physician's order will be initiated within a timely manner by the director of nurses and/or designee .Physician Compliance: When the attending physician does not concur or take action on identified irregularities, the facility will communicate to the physician that is required that the physician document the clinical reasoning for continued use of irregularities. If the physician has continued non-compliance .failure to respond to the irregularities, request the facility medical director to assist with further communication with the physician to reemphasize the need for compliance with identified irregularities. Event ID: Facility ID: 675938 If continuation sheet Page 13 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 6 staff (MA F & LVN A) reviewed for infection control, in that: Residents Affected - Some 1. MA F did not sanitize her hands prior to administering eye drops to Resident #37. 2. LVN A did not sanitize her hands prior to administering insulin to Resident #45, removed gloves from a box, and placed them in her pocket to use. These deficient practices could place residents at-risk for infections. The findings included: 1. During an observation on 10/26/23 at 10:16 a.m. MA F planned to administer eye drops to Resident #37. MA F sanitized her hands at the medication cart. MA F carried the medication into the room and closed the door with her bare hands. Without sanitizing her hands, MA F went to the resident's bedside tabled, grabbed a pair of gloves, put on the gloves. MA F then pulled down the resident's lower eyelid, with her gloved hands, and administered 2 drops in each eye. During an interview on 10/26/23 at 3:11 p.m. MA F stated she sanitized her hands after each resident and washes them after every 3 residents. MA F stated she sanitized them before giving medications at the medication cart. MA F stated she put on gloves after touching the door so she did not see why it was a concern for infection control if she touched the resident's eye with gloved hands. MA F stated she had not been trained to sanitize her hands immediately prior to putting on gloves. This surveyor asked MA F if she knew if the door was dirty or clean. MA F then stated she should clean her hands after touching an object she is not sure was dirty or clean, but she thought if she put on gloves after touching the door it was okay. MA F stated the purpose of sanitizing or washing her hands is to disinfect germs and prevent the spread of viruses, so you do not get anyone sick. 2. During an observation on 10/26/23 at 10:19 a.m. LVN A planned to administer insulin to Resident #45. LVN A entered Resident #45's room with a basket of supplies she set up following proper infection control prevention. LVN A closed the resident's door with her bare hands. LVN A pulled the curtains closed with her bare hands. LVN A went to the residents bedside, did not sanitize her hands, pulled a pair of gloves out of her pocket and put them on. LVN A then cleaned the residents injection site with an alcohol swab and administered insulin to the resident with an insulin syringe. During an interview on 10/26/23 at 3:43 p.m. LVN A stated she should sanitize her hands prior to putting on gloves and after removing them. LVN A stated she did go wash her hands after she was done administering the insulin. LVN A stated the facility did provide hand sanitizer and she could have taken a bottle in the room with her along with the other supplies. LVN A stated she put her gloves in her pocket because they did not have boxes of gloves available for them to use on the walls in the Residents rooms and it would have been helpful if they did. LVN A stated she should not put her gloves in her pocket because items such as her keys could contaminate them and spread infection. During an interview on 10/26/23 with RN E stated there was hand sanitizer available for the staff to use on the wall inside resident rooms. RN E stated it is not best practice to keep gloves in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 14 of 15 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 pocket. RN E stated there is a potential for infection if something is dirty. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Fundamentals of Infection Control Precautions, dated 03/2023, stated a variety of infection control measures are used or decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand hygiene: hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: . before and after performing any invasive procedure (e.g, finger stick blood sampling) . before and after assisting a resident with personal care (e.g., oral care, bathing) .Gloving: gloves are worn for three important reasons . wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use and the hands can become contaminated during removal of the gloves. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 15 of 15