Inspection·April 19, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm his urine. Resident #4 said he does not remember seeing a urologist (a medical doctor specializing in conditions that affect the urinary tract in men, women, and children). Record review of Resident #4's hospital discharge paperwork did not indicate an order or care for an indwelling catheter. Residents Affected - Few During an interview on 04/17/23 at 10:25 a.m., LVN A said she was aware Resident #4 had an indwelling catheter. LVN A said she was recently hired and was not aware why Resident #4 had the indwelling catheter. LVN A reviewed Resident #4's orders and verified he did not have a diagnosis or an order for his indwelling catheter. LVN A said Resident #4 should have had an order and diagnosis for his indwelling catheter, but he did not. LVN C said failure to have a diagnosis or order could lead to Resident #4 not receiving the treatment he needed or having an indwelling catheter for an unknown reason. During an interview on 04/18/23 at 4:10 p.m., LVN B said she was Resident #4's primary nurse. LVN B said she was the nurse who admitted Resident #4. LVN B said the ADON or DON had started Resident #4's orders in the system and she completed the routine order that applied to the indwelling catheter. LVN B said she was not aware Resident #4 did not have an order or diagnosis for his indwelling catheter until questioned by surveyor. LVN B said she thought Resident #4 had the indwelling catheter because of his wounds. LVN B said she was not sure how the diagnosis or the order was overlooked or not updated since admission. LVN B said all residents should have a diagnosis and an order for any care they were receiving. During an interview on 04/19/23 at 10:20 a.m., the DON said the floor nurses were responsible for inputting orders when residents admitted to the facility. She said the ADON and herself would start the orders when they could and charge nurses' reviews and updates the orders as needed when they arrived at the facility. The DON said she was responsible for checking new admissions during morning meeting. The DON said she missed Resident #4's order and diagnosis for the indwelling catheter. She said failure to have orders or diagnosis could lead to staff no knowing how to properly care for Resident #4. During an interview on 04/19/23 at 10:23 a.m., the ADON said she and the DON would try to start the admission orders and the charge nurses were responsible to ensure all admitting orders were correct once residents arrived at the facility. The ADON said they usually reviewed new/admission orders in the morning meeting and was not sure why Resident #4 orders and diagnosis were not caught during these times. She stated they had to have orders for the care of the indwelling catheter as well as the diagnoses to support the ongoing need of the indwelling catheter. The ADON said she thought Resident #4 had a diagnosis for his indwelling catheter and would reach out to his physician. During an interview on 04/18/23 at 12:30 p.m., the ADON said she talked to Resident #4's primary doctor. The primary doctor said Resident #4 had a diagnosis of bladder neck obstruction and he would send over his progress note. During an interview on 04/18/23 at 12:40 p.m., the Administrator said the admitting nurse was responsible for inputting any orders on admission and following through with the orders. She said she expected nurse managers to review all new admissions or new orders in the morning meeting and update as needed. She said failure to follow through with orders could have things missed. Record review of Resident #4's Physician progress note dated 04/05/23 revealed diagnosis of bladder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 2 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0690 neck obstruction and recent hospitalized with osteomyelitis and UTI. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled, admission Assessment and Follow Residents Affected - Few Up, dated 09/12 indicated, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial conditions upon admission for the purpose of managing the residents, initial initiating the care plan, and completing required assessment instruments, including the MDS. Steps in the procedure, #12 contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Reporting, #1 notify the supervisor and the attending physician of immediate needs that the resident may have and report other information in accordance with facility policy and professional standards of practice. Record review of facility policy titled, Guidelines for Charting and Documentation, dated 04/12 indicated, Physician order, I. Foley catheter, #1 specify why Foley catheter was needed #2, the size (i.e., #18 French foley catheter to straight drain) and the frequency of change, #3 Catheter care, specific what was to be done or according to facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 3 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 respiratory care was provided consistent with professional standards of practice for 2 of 2 residents (Resident #22 and Resident #6) reviewed for respiratory care and services. Residents Affected - Few 1. The facility failed to ensure Resident #22's oxygen filter was cleaned. 2. The facility failed to obtain a physician order for oxygen for Resident #6. These failures could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: 1. Record review of Resident #22's face sheet, dated 04/17/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), congestive heart failure (heart muscle does not pump blood as well as it should), essential hypertension (high blood pressure), and asthma (condition in which the airways become inflamed, narrow and swell, and produce extra mucus which makes it difficult to breathe). Record review of Resident #22's quarterly MDS assessment, dated 03/23/23, indicated she was usually understood and usually understood others. Resident #22's had a BIMS score of 5, which indicated she had severe cognitive impairment. The MDS indicated Resident #22 did not reject care necessary to achieve the resident's health and well-being and was receiving oxygen therapy. Record review of Resident #22's order summary report, dated 04/17/23, indicated she had the following orders: *Change nasal cannula and humidifier every week on Sundays. Date and initial tubing and humidifier when changing. Clean oxygen filter and concentrator. *Oxygen at 2L/min to 3L/min per nasal cannula continuously. Check oxygen every shift related to chronic obstructive pulmonary disease. Record review of Resident #22's comprehensive care plan, dated 08/19/21 and revised on 10/13/22, indicated Resident #22 had altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease with interventions for oxygen via nasal cannula at 2-3 liters continuously. During an observation on 04/16/23 at 09:03 a.m., Resident #22 was in bed and receiving oxygen at 3 liters per minute via nasal cannula. Resident #22's oxygen concentrator filter had gray like substance on it. During an observation on 04/17/23 at 08:54 a.m., Resident #22 was in bed and receiving oxygen at 3 liters per minute via nasal cannula. The filter on Resident #22's oxygen concentrator continued to have gray like substance on it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 4 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/17/23 at 02:09 p.m., LVN J said oxygen filters were cleaned weekly on Sunday during the night shift. LVN J said the night nurse was responsible for ensuring the task was completed but it was also the responsibility of the day shift nurse to follow up that it was done. LVN J said by not ensuring the oxygen filters were cleaned Resident #22 was at risk for having incorrect oxygen saturation readings or the oxygen concentrator could not work properly. Residents Affected - Few During an interview on 04/17/23 at 2:25 p.m., the ADON said she expected the night nurse to clean the oxygen filters weekly and as needed. The ADON said the task was assigned for Sunday night and to be completed by the nurse. The ADON said by not cleaning the oxygen filters, the oxygen concentrator could clog up and not give the correct amount of oxygen or cause infection. The ADON said it was everyone's responsibility to ensure the oxygen filters were cleaned. The ADON said administrative personnel did rounds weekly and that was something they checked for. During an interview on 04/18/23 at 10:31 a.m., LVN N said she worked Sunday night (04/16/23), and she was unable to recall if she had cleaned the filter on Resident #22's oxygen concentrator due to a busy night. LVN N said by not cleaning the oxygen filter Resident #22 was at risk for not receiving the required oxygen needed. During an interview on 04/19/23 at 10:10 a.m., the DON said she expected oxygen filters to be cleaned weekly. The DON said the night nurse was responsible for ensuring the oxygen filters were cleaned and completed on Sunday night. The DON said by not cleaning the filters on the oxygen concentrator, Resident #23 was at risk for not receiving the correct amount of oxygen needed to keep her health from deteriorating. During an interview on 04/19/23 at 10:45 a.m., the Administrator said she expected the oxygen filters to be cleaned weekly and as needed. The Administrator said the night nurse was responsible for completing that task and the administrative nurses were responsible for overseeing that it was done. The Administrator said not cleaning the oxygen filters could alter the flow of oxygen to the resident. 2. Record review of Resident #6's face sheet, dated 04/17/23, indicated she was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included local infection of the skin, atrial fibrillation (irregular heart rate), and heart failure (heart muscle does not pump blood as well as it should). Record review of Resident #6's quarterly MDS, dated [DATE], indicated she was usually understood and usually understood others. The MDS indicated Resident #6's BIMS score of 9, which indicated she had moderate cognitive impairment. Resident #6 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing. Resident #6 was totally dependent on transfers and toileting. The MDS indicated Resident #6 was receiving oxygen therapy. Record review Resident #6's order summary report dated 04/17/23, did not reveal an order for oxygen. Record review of Nurse Practitioner's progress note, dated 04/05/2023, indicated Resident #6 .is also on O2 (oxygen) via nasal cannula continuously at 2 L/NC. During an observation on 04/16/23 at 09:29 a.m., Resident #6 was lying in bed and receiving oxygen at 4.5 liters per minute via nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 5 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 04/17/23 at 08:58 a.m., Resident #6 was lying in bed and receiving oxygen at 4.5 liters per minute via nasal cannula. Resident #6 said she had been receiving oxygen since 04/09/23 due to shortness of breath. During an interview on 04/17/23 at 02:09 p.m., LVN J said Resident #6 had been receiving oxygen since he started working at the facility approximately a month ago. LVN J was unsure of why Resident #6 did not have an order for oxygen. LVN J said the nurse obtaining the order for oxygen was responsible for ensuring the order was transcribed in the resident's medical record. LVN J said he was also responsible for ensuring Resident #6 had an order for oxygen. LVN J said by not having an order for oxygen, Resident #6 was at risk for not getting the ordered amount of oxygen. During an interview on 04/17/23 at 02:25 p.m., the ADON said Resident #6 should have had order for oxygen since oxygen was considered a medication and required monitoring. The ADON said without an order the nurse would be unsure of what to set the oxygen at placing Resident #6 at risk for receiving too much or not enough oxygen. The ADON said the nurse who obtained the order was responsible for ensuring the order was transcribed in the resident's medical record. During an interview on 04/19/23 at 10:10, the DON said she expected Resident #6 to have an order for oxygen since oxygen was considered a medication. The DON said Resident #6 had received oxygen in the past and had requested to have oxygen restarted. The DON said they should have addressed her need for oxygen in the progress note and should have obtained an order for oxygen. The DON said Resident #6 was at risk for receiving too much or not enough oxygen. The DON said she was ultimately responsible for ensuring Resident #6 had an oxygen order. During an interview on 04/19/23 at 10:45 a.m., the Administrator said she expected Resident #6 to have an order for oxygen as it was considered a medical treatment that required a physician's order. The administrator said the nurse obtaining the order was responsible for ensuring the order was transcribed. The administrator said the administrative nurses were responsible for ensuring all orders were accurate. The administrator said by not having an order for oxygen, Resident #6 was at risk for receiving too much or not enough oxygen. Record review of the facility's policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised 11/2011, indicated, .Infection Control Considerations related to Oxygen Administration . wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry . Record review of the facility's policy titled, Oxygen Administration, revised October 2010, indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 6 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 2 of 6 residents (Resident #13 and Resident #7) reviewed for medication pass. The facility failed to ensure Resident #13 had a sufficient supply of medications which resulted in Resident #13 missing 4 prescribed medications. The facility failed to ensure Resident #7 had a sufficient supply of medications which resulted in Resident #7 missing 3 prescribed medications. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #13's face sheet, dated 04/17/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He had diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing problems), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (higher than normal blood pressure), and chronic diastolic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #13's quarterly MDS, dated [DATE], indicated he was usually able to make himself understood and was usually able to understand others. He had a BIMS score of 12 which indicated moderately impaired cognition. He did not exhibit behaviors of rejection of care or wandering. He required supervision for all activities of daily living except dressing, which required limited assistance. The MDS indicated he had diagnoses which included heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), coronary artery disease (a narrowing or blockage of your coronary arteries, usually due to plaque buildup), and hypertension (higher than normal blood pressure). Record review of Resident #13's physician's orders, dated 04/17/23, indicated Resident #13 was ordered the following: *Crestor tablet 20mg, give 1 tablet by mouth one time a day (used in adults to slow the progression of atherosclerosis [a build-up of plaque in blood vessels that can block blood flow]) *Lisinopril hydrochlorothiazide tablet 20-25mg, give 0.5 tablet by mouth one time a day (a medication used to treat high blood pressure) *Duloxetine HCL capsule delayed release 60mg, give 1 capsule by mouth one time a day (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) *Furosemide tablet 40mg, give 1 tablet by mouth one time a day (a medication used to treat fluid retention) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 7 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0755 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #13's MAR, dated 04/19/23, indicated crestor 20mg was held and not administered on 04/17/23 and 04/18/23. Duloxetine 60mg was held and not administered on 04/17/23. Furosemide 40mg was held and not administered on 04/17/23. Lisinopril hydrochlorothiazide 20-25mg was held and not administered on 04/17/23 and 04/18/23. No other held doses for the medications were found for the month of April. Residents Affected - Few 2. Record review of Resident #7's face sheet, dated 04/17/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses which included essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). Record review of Resident #7's annual MDS, dated [DATE], indicated she was usually able to make herself understood and was usually able to understand others. She had a BIMS score of 11 which indicated moderately impaired cognition. She did not exhibit behaviors of rejection of care or wandering. She required supervision assistance with all activities of daily living. Record review of Resident #7's physician's orders, dated 04/17/23, indicated Resident #7 was ordered the following: *Lisinopril tablet 20mg, give 20mg by mouth two times a day for hypertension (a medication used to treat high blood pressure) *Sotalol HCL tablet 80mg, give 0.5 tablet by mouth two times a day (used to treat atrial fibrillation [an irregular and often very rapid heart rhythm that can lead to blood clots in the heart] and other conditions that cause an irregular heartbeat). *Systane Ultra Solution 0.4-0.3%, instill 1 dop in both eyes in the morning for dry eyes (a medication used for the temporary relief of burning and irritation due to dryness of the eye) Record review of Resident #7's MAR, dated 04/19/23, indicated systane ultra-eye drops were held and not administered on 04/17/23 and 04/18/23. Lisinopril tablet 20mg was held and not administered on 04/17/23 for both the AM and PM doses. Sotalol HCL tablet 80mg was held and not administered on 04/17/23 and 04/18/23 for both the AM and PM doses. No other held doses for the medications were found for the month of April. During an observation and interview on 04/17/23 at 08:41 AM, LVN J did not administer Resident #13's duloxetine, furosemide, lisinopril hydrochlorothiazide, or crestor medications. He said he was unable to find the medications in his cart. He said he marked the medications as held in the MAR. During an observation and interview on 04/17/23 at 09:06 AM, LVN J did not administer Resident #7's sotalol, lisinopril, or systane ultra eye drops medications. He said he was unable to find the medications in his cart. He said he marked the medications as held in the MAR. During an interview on 04/17/23 at 09:56 AM, LVN J said he checked the medication room for Resident #13's duloxetine, furosemide, lisinopril hydrochlorothiazide, and crestor and was not able to find the medications. LVN J said checked the medication room for Resident #7's sotalol, lisinopril, and Systane ultra eye drops and was not able to find the medications. LVN J said the medications were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 8 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0755 delivered from the pharmacy. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/17/23 at 11:41 AM, LVN J said he ordered the missing medications on Thursday 04/13/23 when he last worked. He said he had looked for the held medications and he was unable to find them. He said there was an emergency kit and the kit contained medications they could use when they ran out. He said he thought the facility ran out of the medications because the nurse who worked over the weekend did not follow up with the pharmacy to ensure the medications were filled and delivered. Residents Affected - Few During an interview on 04/17/23 at 02:09 PM, LVN J said he was going to call the pharmacy and see why the medications were not delivered. He said that Resident #13 and Resident #7 could have high blood pressures because they did not receive their lisinopril. He said Resident #7 could have an elevated heart rate because she did not receive her sotalol. He said Resident #13 could have increased fluid retention due to not receiving his furosemide. LVN J said he did not give the medications out of the emergency kit yesterday because he was busy, and he did not have access to the emergency kit. He said he did not report this to the DON or ADON. During an interview and record review on 04/17/23 at 04:02 PM, the ADON provided a copy of LVN J's medication administration competency dated 2/28/23. She said the section labelled Charting - EMAR: medications/treatment included medication administration training. Record review of LVN J's In-service training, dated 02/28/23, indicated that LVN J was trained on medication administration and ordering of medications. During an interview on 04/18/23 at 09:00 AM, LVN J said he did not call the pharmacy yesterday to check on the status of the missing medications. He said he was busy and was unable to contact the pharmacy yesterday. LVN J said the missing medications had not been delivered yet from the pharmacy. During an interview on 04/18/23 at 01:48 PM, the ADON said the duloxetine, furosemide, lisinopril hydrochlorothiazide, and crestor for Resident #13 had been ordered from the pharmacy. She said she was unable to see what day those medications were ordered. She said Resident #7's sotalol, lisinopril, and systane eye drops have been ordered. She said the charge nurses were responsible for reordering medications when the medications were low. She said the process for reordering medications was the nurses should have ordered the medication refills on the EMR which sends a message to the pharmacy that a refill of the medications was needed. The ADON said the charge nurse should have checked with the pharmacy to determine why the medications were not delivered. The ADON said they should have used the emergency kit when they ran out of Resident #13's and Resident #7's medications. She said if the nurse could not get through to the pharmacy, they should have notified the DON or ADON. She said Resident #13 could suffer from swelling/fluid overload by not receiving his furosemide. She said he could suffer high blood pressure or fluid overload because he did not receive his lisinopril hydrochlorothiazide. Resident #7 could have an elevated heart rate or high blood pressure because she did not receive her sotalol and lisinopril. She said LVN J should have notified the ADON or DON as soon as he realized he was out of the medications and he could not access the emergency kit. During an interview on 04/18/23 at 02:05 PM, LVN A said the process for reordering medications was she orders refills as soon as the medication had only one line left in the card. She said she would order refills through the charting system or call the pharmacy. She said if the medication was not on hand, she would check the emergency kit. She said if the medication was not in the emergency kit, she would call the pharmacy and then she would notify the ADON. She said she would call the doctor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 9 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to see if there was an alternative to the medication. She said she would keep calling the pharmacy and notifying the ADON. She said she would call the doctor if she had to hold resident medications such as furosemide. During an interview on 04/19/23 at 09:30 AM Pharmacist M said Resident #13's duloxetine, furosemide, and lisinopril hydrochlorothiazide were ordered and filled on 03/13/23 and 04/18/23. He said the crestor was ordered and filled on 03/13/23 and 04/17/23. He said the pharmacy did not receive an order for any of those medications between 03/13/23 and 04/17/23. He said Resident #7's sotalol and lisinopril were ordered and filled on 03/20/23 and 04/18/23. He said the pharmacy did not receive an order for those medications between 03/20/23 and 04/18/23. He said he also checked faxes and documented phone calls and did not find any record of medication orders for Resident #13 and Resident #7 between 03/13/23 and 04/18/23. During an interview on 04/19/23 at 10:07 AM, the ADON said the nurses were responsible for ordering medications before they ran out and no one monitored them to see if low medications were being reordered. She said as a nurse, she would have reordered the medication as soon as there were 7 days of medications left on the card. During an interview on 04/19/23 at 10:11 AM, the Administrator said the nursing staff were responsible for ensuring medications did not run out. She said the nursing staff were responsible for ordering the medications. She said she did not think anybody was assigned to monitor staff and ensure medications were being reordered timely. She said she expected the nursing staff to refill the medications and have them in the facility before they ran out. The administrator said the ADON and DON were ultimately responsible for ensuring the nursing staff were ordering medications and not running out of them. Resident #13 could potentially have a worsened condition because he did not receive the furosemide or lisinopril. She said there was a potential for harm to Resident #13 by omitting his medications during his medication pass. She said Resident #7 had potential for harm including increased heart rate and increased blood pressure because she did not receive the sotalol or lisinopril. During an interview on 04/19/23 at 11:20 AM, the DON said the direct care nurse was responsible for ordering medications when they were low. She said the DON was ultimately responsible for medication administration. She said the DON was responsible ultimately for ensuring medications were ordered and followed up on. She said the process for ensuring medications were not missed was that the direct care nurse should have ensured the medication was ordered, then they should have checked the emergency kit. She said if the nurse could not get the medication out of the emergency kit they were supposed to bring it to the attention of the DON. She said the nurses should have ordered a refill of the medication when there were around 4 days of the medication remaining. She said no one was monitoring the nurses to ensure medications were not running out or being missed. The process for ordering medications was nurses should order a medication refill through the chart, then the pharmacy receives the refill and sends the medication to the facility. The direct care nurses were responsible for checking with the pharmacy if medications were not delivered. She said if they could not reach the pharmacy then they should have notified the ADON or DON. She said Resident #13 could suffer worsened congestive heart failure or his blood pressure could be elevated, because his Furosemide and Lisinopril were missed. She said Resident #7 could experience elevated blood pressure and heart rate because her Sotalol and Lisinopril were missed. She said LVN J was a new nurse and did not yet have access to the emergency kit. Record review of the facility's undated Medication Administration Policy stated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 10 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0755 .4. Dispensing Practices Level of Harm - Minimal harm or potential for actual harm 4.1 Pharmacy Ordering Process . .4.1.2. Refill Orders Residents Affected - Few The following forms or methods are accepted means of submitting refill orders to the pharmacy: For facilities with integrated EHR, the facility may transmit refill request via facility's EHR. In addition, the following may be used Refill reorder form: prescription label stickers are placed on the reorder form and faxed to the pharmacy fax line . .[NAME] Link .the web portal where refill orders can be submitted to the pharmacy. The refill order may be called in if the circumstances require it. Refill orders will be delivered on the first respective facility run of the following business day . .4.1.4. Emergency Kits First Dose Medication Cabinet The pharmacy will provide the first dose medication dispensing cabinet (emergency kit) as the first dose solution. The emergency kit is intended to be used to ensure immediate medication availability when needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 11 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0759 Ensure medication error rates are not 5 percent or greater. 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 it was free of a medication error rate of 5 percent or greater. The facility had a medication error rate of 21.21%, based on 7 errors out of 33 opportunities, which involved 2 of 6 residents (Resident #13 and Resident #7) reviewed for medication administration. Residents Affected - Some The facility failed to administer Resident #13's duloxetine (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) as ordered. The facility failed to administer Resident #13's furosemide (a medication used to treat fluid retention) as ordered. The facility failed to administer Resident #13's lisinopril Hydrochlorothiazide (a medication used to treat high blood pressure) as ordered. The facility failed to administer Resident #13's crestor (used in adults to slow the progression of atherosclerosis [a build-up of plaque in blood vessels that can block blood flow]) as ordered. The facility failed to administer Resident #7's sotalol (used to treat atrial fibrillation [an irregular and often very rapid heart rhythm that can lead to blood clots in the heart] and other conditions that cause an irregular heartbeat) as ordered. The facility failed to administer Resident #7's lisinopril (a medication used to treat high blood pressure) as ordered. The facility failed to administer Resident #7's systane ultra eye drops (a medication used for the temporary relief of burning and irritation due to dryness of the eye) as ordered. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #13's face sheet, dated 04/17/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He had diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing problems), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (higher than normal blood pressure), and chronic diastolic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #13's quarterly MDS, dated [DATE], indicated he was usually able to make himself understood and was usually able to understand others. He had a BIMS score of 12 which indicated moderately impaired cognition. He did not exhibit behaviors of rejection of care or wandering. He required supervision for all activities of daily living except dressing, which required limited assistance. The MDS indicated he had diagnoses which included heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), coronary artery disease (a narrowing or blockage of your coronary arteries, usually due to plaque buildup), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 12 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0759 and hypertension (higher than normal blood pressure). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #13's physician's orders, dated 04/17/23, indicated Resident #13 was ordered the following: Residents Affected - Some *Crestor tablet 20mg, give 1 tablet by mouth one time a day (used in adults to slow the progression of atherosclerosis [a build-up of plaque in blood vessels that can block blood flow]) *Lisinopril hydrochlorothiazide tablet 20-25mg, give 0.5 tablet by mouth one time a day (a medication used to treat high blood pressure) *Duloxetine HCL capsule delayed release 60mg, give 1 capsule by mouth one time a day (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) *Furosemide tablet 40mg, give 1 tablet by mouth one time a day (a medication used to treat fluid retention) Record review of Resident #13's MAR, dated 04/19/23, indicated crestor 20mg was held and not administered on 04/17/23 and 04/18/23. Duloxetine 60mg was held and not administered on 04/17/23. Furosemide 40mg was held and not administered on 04/17/23. Lisinopril hydrochlorothiazide 20-25mg was held and not administered on 04/17/23 and 04/18/23. No other held doses for the medications were found for the month of April. 2. Record review of Resident #7's face sheet, dated 04/17/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses which included essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). Record review of Resident #7's annual MDS, dated [DATE], indicated she was usually able to make herself understood and was usually able to understand others. She had a BIMS score of 11 which indicated moderately impaired cognition. She did not exhibit behaviors of rejection of care or wandering. She required supervision assistance with all activities of daily living. Record review of Resident #7's physician's orders, dated 04/17/23, indicated Resident #7 was ordered the following: *Lisinopril tablet 20mg, give 20mg by mouth two times a day for hypertension (a medication used to treat high blood pressure) *Sotalol HCL tablet 80mg, give 0.5 tablet by mouth two times a day (used to treat atrial fibrillation [an irregular and often very rapid heart rhythm that can lead to blood clots in the heart] and other conditions that cause an irregular heartbeat). *Systane Ultra Solution 0.4-0.3%, instill 1 dop in both eyes in the morning for dry eyes (a medication used for the temporary relief of burning and irritation due to dryness of the eye) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 13 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0759 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #7's MAR, dated 04/19/23, indicated systane ultra eye drops were held and not administered on 04/17/23 and 04/18/23. Lisinopril tablet 20mg was held and not administered on 04/17/23 for both the AM and PM doses. Sotalol HCL tablet 80mg was held and not administered on 04/17/23 and 04/18/23 for both the AM and PM doses. No other held doses for the medications were found for the month of April. Residents Affected - Some During an observation and interview on 04/17/23 at 08:41 AM, LVN J did not administer Resident #13's duloxetine, furosemide, lisinopril hydrochlorothiazide, or crestor medications. He said he was unable to find the medications in his cart. He said he marked the medications as held in the MAR. During an observation and interview on 04/17/23 at 09:06 AM, LVN J did not administer Resident #7's sotalol, lisinopril, or systane ultra eye drops medications. He said he was unable to find the medications in his cart. He said he marked the medications as held in the MAR. During an interview on 04/17/23 at 09:56 AM, LVN J said he checked the medication room for Resident #13's duloxetine, furosemide, lisinopril hydrochlorothiazide, and crestor and was not able to find the medications. LVN J said checked the medication room for Resident #7's sotalol, lisinopril, and Systane ultra eye drops and was not able to find the medications. LVN J said the medications were not delivered from the pharmacy. During an interview on 04/17/23 at 11:41 AM, LVN J said he ordered the missing medications on Thursday 04/13/23 when he last worked. He said he had looked for the held medications and he was unable to find them. He said there was an emergency kit and the kit contained medications they could use when they ran out. He said he thought the facility ran out of the medications because the nurse who worked over the weekend did not follow up with the pharmacy to ensure the medications were filled and delivered. During an interview on 04/17/23 at 02:09 PM, LVN J said he was going to call the pharmacy and see why the medications were not delivered. He said that Resident #13 and Resident #7 could have high blood pressures because they did not receive their lisinopril. He said Resident #7 could have an elevated heart rate because she did not receive her sotalol. He said Resident #13 could have increased fluid retention due to not receiving his furosemide. LVN J said he did not give the medications out of the emergency kit yesterday because he was busy, and he did not have access to the emergency kit. He said he did not report this to the DON or ADON. During an interview and record review on 04/17/23 at 04:02 PM, the ADON provided a copy of LVN J's medication administration competency dated 2/28/23. She said the section labelled Charting - EMAR: medications/treatment included medication administration training. Record review of LVN J's In-service training, dated 02/28/23, indicated that LVN J was trained on medication administration and ordering of medications. During an interview on 04/18/23 at 09:00 AM, LVN J said he did not call the pharmacy yesterday to check on the status of the missing medications. He said he was busy and was unable to contact the pharmacy yesterday. LVN J said the missing medications had not been delivered yet from the pharmacy. During an interview on 04/18/23 at 01:48 PM, the ADON said the duloxetine, furosemide, lisinopril hydrochlorothiazide, and crestor for Resident #13 had been ordered from the pharmacy. She said she was unable to see what day those medications were ordered. She said Resident #7's sotalol, lisinopril, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 14 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and systane eye drops have been ordered. She said the charge nurses were responsible for reordering medications when the medications were low. She said the process for reordering medications was the nurses should have ordered the medication refills on the EMR which sends a message to the pharmacy that a refill of the medications was needed. The ADON said the charge nurse should have checked with the pharmacy to determine why the medications were not delivered. The ADON said they should have used the emergency kit when they ran out of Resident #13's and Resident #7's medications. She said if the nurse could not get through to the pharmacy, they should have notified the DON or ADON. She said Resident #13 could suffer from swelling/fluid overload by not receiving his furosemide. She said he could suffer high blood pressure or fluid overload because he did not receive his lisinopril hydrochlorothiazide. Resident #7 could have an elevated heart rate or high blood pressure because she did not receive her sotalol and lisinopril. She said LVN J should have notified the ADON or DON as soon as he realized he was out of the medications and he could not access the emergency kit. During an interview on 04/18/23 at 02:05 PM, LVN A said the process for reordering medications was she orders refills as soon as the medication had only one line left in the card. She said she would order refills through the charting system or call the pharmacy. She said if the medication was not on hand, she would check the emergency kit. She said if the medication was not in the emergency kit, she would call pharmacy and then she would notify the ADON. She said she would call the doctor to see if there was an alternative to the medication. She said she would keep calling the pharmacy and notifying the ADON. She said she would call the doctor if she had to hold resident medications such as furosemide. During an interview on 04/19/23 at 09:30 AM Pharmacist M said Resident #13's duloxetine, furosemide, and lisinopril hydrochlorothiazide were ordered and filled on 03/13/23 and 04/18/23. He said the crestor was ordered and filled on 03/13/23 and 04/17/23. He said the pharmacy did not receive an order for any of those medications between 03/13/23 and 04/17/23. He said Resident #7's sotalol and lisinopril were ordered and filled on 03/20/23 and 04/18/23. He said the pharmacy did not receive an order for those medications between 03/20/23 and 04/18/23. He also checked faxes and documented phone calls and did not find any record of medication orders for Resident #13 and Resident #7 between 03/13/23 and 04/18/23. During an interview on 04/19/23 at 10:07 AM, the ADON said the nurses were responsible for ordering medications before they ran out and no one monitored them to see if low medications were being reordered. She said as a nurse, she would have reordered the medication as soon as there were 7 days of medications left on the card. During an interview on 04/19/23 at 10:11 AM, the Administrator said the nursing staff were responsible for ensuring medications did not run out. She said the nursing staff were responsible for ordering the medications. She said she did not think anybody was assigned to monitor staff and ensure medications were being reordered timely. She said she expected the nursing staff to refill the medications and have them in the facility before they ran out. The administrator said the ADON and DON were ultimately responsible for ensuring the nursing staff were ordering medications and not running out of them. Resident #13 could potentially have a worsened condition because he did not receive the furosemide or lisinopril. She said there was a potential for harm to Resident #13 by omitting his medications during his medication pass. She said Resident #7 had potential for harm including increased heart rate and increased blood pressure because she did not receive the sotalol or lisinopril. During an interview on 04/19/23 at 11:20 AM, the DON said the direct care nurse was responsible for ordering medications when they were low. She said the DON was ultimately responsible for medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 15 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administration. She said the DON was responsible ultimately for ensuring medications were ordered and followed up on. She said the process for ensuring medications were not missed was that the direct care nurse should have ensured the medication was ordered, then they should have checked the emergency kit. She said if the nurse could not get the medication out of the emergency kit they were supposed to bring it to the attention of the DON. She said the nurses should have ordered a refill of the medication when there were around 4 days of the medication remaining. She said no one was monitoring the nurses to ensure medications were not running out or being missed. The process for ordering medications was nurses should order a medication refill through the chart, then the pharmacy receives the refill and sends the medication to the facility. The direct care nurses were responsible for checking with the pharmacy if medications were not delivered. She said if they could not reach the pharmacy then they should have notified the ADON or DON. She said Resident #13 could suffer worsened congestive heart failure or his blood pressure could be elevated, because his Furosemide and Lisinopril were missed. She said Resident #7 could experience elevated blood pressure and heart rate because her Sotalol and Lisinopril were missed. She said LVN J was a new nurse and did not yet have access to the emergency kit. Record review of the facility's undated Medication Administration Policy stated: .4. Dispensing Practices 4.1 Pharmacy Ordering Process . .4.1.2. Refill Orders The following forms or methods are accepted means of submitting refill orders to the pharmacy: For facilities with integrated EHR, the facility may transmit refill request via facility's EHR. In addition, the following may be used Refill reorder form: prescription label stickers are placed on the reorder form and faxed to the pharmacy fax line . .[NAME] Link .the web portal where refill orders can be submitted to the pharmacy. The refill order may be called in if the circumstances require it. Refill orders will be delivered on the first respective facility run of the following business day . .4.1.4. Emergency Kits First Dose Medication Cabinet The pharmacy will provide the first dose medication dispensing cabinet (emergency kit) as the first dose solution. The emergency kit is intended to be used to ensure immediate medication availability when needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 16 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medication errors for 1 of 6 residents reviewed for medication pass. (Resident #13) Residents Affected - Few The facility failed to ensure Resident #13 received his furosemide (a medication used to treat fluid retention) as ordered by the physician. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #13's face sheet, dated 04/17/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He had diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing problems), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (higher than normal blood pressure), and chronic diastolic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #13's quarterly MDS, dated [DATE], indicated he was usually able to make himself understood and was usually able to understand others. He had a BIMS score of 12 which indicated moderately impaired cognition. He did not exhibit behaviors of rejection of care or wandering. He required supervision for all activities of daily living except dressing, which required limited assistance. The MDS indicated he had diagnoses which included heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), coronary artery disease (a narrowing or blockage of your coronary arteries, usually due to plaque buildup), and hypertension (higher than normal blood pressure). Record review of Resident #13's physician's orders, dated 04/17/23, indicated Resident #13 was ordered furosemide tablet 40mg, give 1 tablet by mouth one time a day (a medication used to treat fluid retention). Record review of Resident #13's MAR, dated 04/19/23, indicated furosemide 40mg was held and not administered on 04/17/23. No other doses were marked as held on the MAR for the month of April. During an observation and interview on 04/17/23 at 08:41 AM, LVN J did not administer Resident #13's furosemide medication. He said he was unable to find the medication in his cart. He said he marked the medication as held in the MAR. During an interview on 04/17/23 at 09:56 AM, LVN J said he checked the medication room for Resident #13's furosemide and was not able to find the medication. LVN J said the medication was not delivered from the pharmacy. During an interview on 04/17/23 at 11:41 AM, LVN J said he ordered Resident #13's furosemide on Thursday 04/13/23 when he last worked. He said he had looked for Resident #13's furosemide and he was unable to find the medication. He said there was an emergency kit and the kit contained medications they could use when they ran out. He said he thought the facility ran out of Resident #13's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 17 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few furosemide because the nurse who worked over the weekend did not follow up with the pharmacy to ensure the medication was filled and delivered. During an interview on 04/17/23 at 02:09 PM, LVN J said he was going to call the pharmacy and see why the medication was not delivered. He said Resident #13 could have increased fluid retention due to not receiving his furosemide. LVN J said he did not give the medication out of the Emergency kit yesterday because he was busy, and he did not have access to the emergency kit. He said he did not report this to the DON or ADON. During an interview and record review on 04/17/23 at 04:02 PM, the ADON provided a copy of LVN J's medication administration competency dated 2/28/23. She said the section labelled Charting - EMAR: medications/treatment included medication administration training. Record review of LVN J's In-service training, dated 02/28/23, indicated that LVN J was trained on medication administration and ordering of medications. During an interview on 04/18/23 at 09:00 AM, LVN J said he did not call the pharmacy yesterday to check on the status of Resident #13's furosemide. He said he was busy and was unable to contact the pharmacy yesterday. LVN J said Resident #13's furosemide had not been delivered yet from the pharmacy. During an interview on 04/18/23 at 01:48 PM, the ADON said the furosemide for Resident #13 had been ordered from the pharmacy. She said she was unable to see what day the furosemide medication was ordered. She said the charge nurses were responsible for reordering medications when the medications were low. She said the process for reordering medications was the nurses should have ordered the medication refills on the EMR which sends a message to the pharmacy that a refill of the medication was needed. The ADON said the charge nurse should have checked with the pharmacy to determine why the medication was not delivered. The ADON said they should have used the emergency kit when they ran out of Resident #13's furosemide. She said if the nurse could not get through to the pharmacy, they should have notified the DON or ADON. She said Resident #13 could suffer from swelling/fluid overload by not receiving his furosemide. She said LVN J should have notified the ADON or DON as soon as he realized he was out of Resident #13's furosemide and he could not access the emergency kit. During an interview on 04/18/23 at 02:05 PM, LVN A said the process for reordering medications was she orders refills as soon as the medication had only one line left in the card. She said she would order refills through the charting system or call the pharmacy. She said if the medication was not on hand, she would check the emergency kit. She said if the medication was not in the emergency kit, she would call pharmacy and then she would notify the ADON. She said she would call the doctor to see if there was an alternative to the medication. She said she would keep calling the pharmacy and notifying the ADON. She said she would call the doctor if she had to hold resident medications such as furosemide. During an interview on 04/19/23 at 09:30 AM, Pharmacist M said Resident #13's furosemide was ordered and filled on 03/13/23 and 04/18/23. He said the pharmacy did not receive an order for the furosemide medication between 03/13/23 and 04/18/23. He also checked faxes and documented phone calls and did not find any record of medication orders for Resident #13 between 03/13/23 and 04/18/23. During an interview on 04/19/23 at 10:07 AM, the ADON said the nurses were responsible for ordering medications before they ran out and no one monitored them to see if low medications were being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 18 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reordered. She said as a nurse, she would have reordered the medication as soon as there were 7 days of medications left in the card. During an interview on 04/19/23 at 10:11 AM, the Administrator said the nursing staff were responsible for ensuring medications did not run out. She said the nursing staff were responsible for ordering the medications. She said she did not think anybody was assigned to monitor staff and ensure medications were being reordered timely. She said she expected the nursing staff to refill the medications and have them in the facility before they ran out. The administrator said the ADON and DON were ultimately responsible for ensuring the nursing staff were ordering medications and not running out of them. Resident #13 could potentially have a worsened condition because he did not receive his furosemide. She said there was a potential for harm to Resident #13 by omitting his furosemide during his medication pass. During an interview on 04/19/23 at 11:20 AM, the DON said the direct care nurse was responsible for ordering medications when they were low. She said the DON was ultimately responsible for medication administration. She said the DON was responsible ultimately for ensuring medications were ordered and followed up on. She said the process for ensuring medications were not missed was the direct care nurse should have ensured the medication was ordered, then they should have checked the emergency kit. She said if the nurse could not get the medication out of the emergency kit they were supposed to bring it to the attention of the DON. She said the nurses should have ordered a refill of the medication when there were around 4 days of the medication remaining. She said no one was monitoring the nurses to ensure medications were not running out or being missed. The process for ordering medications was nurses should order a medication refill through the chart, then the pharmacy receives the refill and sends the medication to the facility. The direct care nurses were responsible for checking with the pharmacy if medications were not delivered. She said if they could not reach the pharmacy then they should have notified the ADON or DON. She said Resident #13 could suffer worsened congestive heart failure because his furosemide was missed. She said LVN J was a new nurse and did not yet have access to the emergency kit. Record review of the facility's undated Medication Administration Policy stated: .4. Dispensing Practices 4.1 Pharmacy Ordering Process . .4.1.2. Refill Orders The following forms or methods are accepted means of submitting refill orders to the pharmacy: For facilities with integrated EHR, the facility may transmit refill request via facility's EHR. In addition, the following may be used Refill reorder form: prescription label stickers are placed on the reorder form and faxed to the pharmacy fax line . .[NAME] Link .the web portal where refill orders can be submitted to the pharmacy. The refill order may be called in if the circumstances require it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 19 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 0760 Refill orders will be delivered on the first respective facility run of the following business day . Level of Harm - Minimal harm or potential for actual harm .4.1.4. Emergency Kits First Dose Medication Cabinet Residents Affected - Few The pharmacy will provide the first dose medication dispensing cabinet (emergency kit) as the first dose solution. The emergency kit is intended to be used to ensure immediate medication availability when needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 20 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 13 residents (Residents #3, #6, and #10) reviewed for incontinent care and wound care and 1 of 2 linen carts (Hall 200 cart) reviewed for infection control practices. Residents Affected - Some 1. CNA F failed to change her gloves when going from a dirty to a clean procedure and when her gloves were visibly soiled when performing incontinent care on Resident #10. 2. The facility failed to store linen in a clean area. 3. CNA K failed to change her gloves prior to applying the clean brief and barrier cream to Resident # CNA K failed to perform hand hygiene in between glove changes when she provided incontinent care to Resident #3. 4. LVN A failed to clean Resident #6's wounds after placing the open wounds on the dirty pillow and before applying the clean dressings. These failures could place residents at risk for infections. Findings included: 1.Record review of the undated face sheet indicated Resident #10, a female, admitted [DATE], and readmitted [DATE]. Record review of the consolidated physician's orders dated April 2023 indicated Resident #10 was [AGE] years old with diagnoses that included: high blood pressure (the force of the blood in the artery walls is too high), cerebral infarction, (disruption in the blood supply in the brain), Multiple Sclerosis (the immune system eats away at the protective covering of the nerves), seizures (a burst of uncontrolled electrical activity in brain cells causing stiffness, twitching, or limpness), and depression (feelings of despondency, dejection, inadequacy, and guilt). Record review of the quarterly MDS dated [DATE] indicated Resident #10 had clear speech, was usually understood by others, and usually understood others. She had a BIMS score of 9 that indicated moderate cognitive impairment. Resident #10 required the total assistance of two or more staff for bed mobility. The MDS indicated she had not transferred in the 7-day lookback period. She was always incontinent of bladder and bowel. Record review of the care plan dated 1/13/23 indicated Resident #10 required staff to turn and reposition her in bed and she was bedfast all or most of the time. She required the use of a mechanical lift for transfers. The care plan indicated she had impaired cognitive function/dementia or impaired thought processes related to poor processing and a communication problem related to her cognition. The care plan indicated she had bowel and bladder incontinence. During an observation on 4/17/23 at 10:25 a.m., CNA F performed incontinent care on Resident #10 with the DON assisting. CNA F did not change her gloves after cleaning the front peri area of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 21 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #10. She put the gloves on Resident #10's hip and back to turn her to her side. While CNA F was cleaning Resident #10's back side she got stool on her gloves and did not change her gloves. She smeared stool from her gloves on Resident #10's right hip and leg. CNA F wiped off the stool that was smeared onto Resident #10 with wipes but did not change her gloves and continued with care. She continued to wipe Resident #10's bottom with her visibly soiled gloves. The gloves had stool on her left hand/glove at the end of the thumb and below the left finger outer palm. CNA F did not change her gloves until after she finished cleaning Resident #10's back side. During an interview on 4/17/23 at 10:47 a.m., CNA F said she had been working at the facility for about a month. She said she had been a CNA for 3 years. She said she should have changed her gloves after cleaning the front/peri area of Resident #10 and should not have touched Resident #10 because her gloves were dirty. She said she also should have changed her gloves when they were visibly soiled with stool. She said the danger of not changing her gloves was infection transmission. She said she had passed her CNA competencies since she had been at this facility. She said they did the competencies at hire prior to her working. She said she did not know why she did not change her gloves when she knew she was supposed to. During an interview on 4/17/23 at 11:12 a.m., the DON said she would have changed her gloves immediately if they had stool on them. She said CNA F did not change her gloves after cleaning the front/perineal area of Resident #10. She said she then touched the resident with her dirty/unchanged gloves when she went to turn her to her side. She said she should have changed her gloves immediately when she got stool on them. She said she considered telling her change her gloves a couple of times, but then she did not. She said maybe she should have told her to change her gloves, but she wanted to observe her to see what the facility needed to work on. She said the CNA not changing her gloves was an infection control risk that could cause UTI's (an infection in the bladder) and all sorts of bugs to spread through the facility. She said CNA F had been trained on incontinent care and handwashing and was trained when to change her gloves when they were dirty or visibly soiled. She said she had been trained at this facility prior to working. During an interview on 4/18/23 at 9:04 a.m., CNA G said when doing peri care you cannot change your gloves enough. She said after you clean the front of a resident you change gloves before touching the resident to roll them over to clean their back side. She said if you do not, then you have put dirty gloves on the resident. She said if she got stool on her gloves, she would change her gloves immediately and wash her hands. She said not changing out of dirty gloves was an infection control problem and could spread infections, sickness, and all the above because you don't know what was in urine or stool. She said she was retrained yearly on handwashing and peri-care. She said a nurse would observe her do a peri-care and if she had done handwashing and peri-care properly the nurse would check off each section and validate her proficiency. She said all the CNA's had to have a check-off at least yearly. During an interview on 4/18/23 at 10:53 a.m., the MDS nurse said after a CNA cleaned a resident's front side she should change her gloves before touching the resident or any bedding because her gloves were dirty. She said if the CNA did not change her gloves, she was putting dirty gloves on that resident and anything else she touched. She said not changing out of dirty gloves could spread infection. She said if a CNA got stool on her gloves during care the CNA should immediately take off the gloves, wash her hands and don new/clean gloves. She said not changing dirty gloves was a set up for the spread of infection. During an interview on 04/18/23 at 1:34 p.m., CNA H said when performing peri care after cleaning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 22 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the front part of a resident you would have to change your gloves before putting your hands on a resident and turning them because your gloves would be dirty. She said if you turned a resident or touched a resident with dirty gloves, you could be spreading infection. She said if your gloves were visibly soiled you immediately stopped, washed your hands and changed your gloves. She said, It is a big no-no to continue once your gloves are visibly soiled, especially with stool. She said continuing with visibly soiled gloves presented a danger of spreading infection, viruses, and whatever else could make people sick. During an interview on 04/18/23 at 1:45 p.m., the administrator said she expected gloves to be changed anytime a staff went from dirty to clean. She said if a staff had performed peri care on the front part of a resident, they would have to change their gloves and clean their hands before turning or touching the resident because their gloves would be considered dirty. She said if the CNA turned the resident or touched a resident without changing their gloves there was a danger of infection control issues. She said if another staff was assisting and noticed the CNA had not changed gloves from a dirty to a clean procedure or continued peri care after noticeable stool was on her gloves, she expected the assisting staff to tell her/him she needed to change gloves and wash her hands. During an interview and record review on 04/19/23 at 10:42 a.m., the ADON showed this surveyor the verification of competency for CNA F for handwashing and perineal care. The ADON said she had verified CNA F's competency for handwashing and perineal care on 4/3/23 and indicated her signature was at the bottom of the pages. She said her signature at the bottom of the documents indicated CNA F was proficient in handwashing and perineal care. 2. During an observation on 04/16/23 at 11:30 a.m., the clean linen cart was stored in the supply closet next to two dirty barrels in a room on hall two hundred. During an observation and interview on 04/16/23 at 12:07 p.m., CNA E observed the clean linen cart was next to two barrels in the supply closet. CNA E lifted both barrel tops and verified dirty items were in each barrel. CNA E said the clean linen cart and barrels were stored in the supply closet when they were not being used on the halls. CNA E said dirty barrels should not be stored with clean linen because of cross contamination. During an observation and interview on 04/16/23 at 12:09 p.m., Housekeeper D came into the supply closet to count linen. Housekeeper D said that was where she would usually locate the clean linen cart when not on the hallway. Housekeeper D said in the laundry room she was aware clean and dirty should not be stored together because of cross contamination but did not think about it being the same in the supply closet. During an interview on 04/16/23 at 12:12 p.m., CNA C said she was new to the facility and did not know where to store clean linen and dirty barrels so she stored them together. CNA C confirmed the linen cart was next to two dirty barrels stored in the supply closet on hall two hundred. CNA C said staff members did not show her where to store linen and barrels and she did not ask. CNA C said she knew the linen cart should not be next to the dirty barrels because of the risk for cross contamination but did not think about it until surveyor questioned. During an observation and interview on 04/16/23 at 12:17 p.m., the ADON opened the supply closet and verified clean linen was next to two dirty barrels. The ADON said the charge nurses should ensure staff knows where to store clean linen but she was the overseer as the infection preventionist. The ADON said clean linen should not be stored next to dirty barrels because of cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 23 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 04/19/23 at 10:49 a.m., the DON said clean linen and dirty barrels should not be stored together. The DON said the charge nurses were responsible to ensure staff was not storing clean with dirty. The DON said clean linen and barrels should be stored separately because of cross contamination or infection risk. During an interview on 04/19/23 at 11:13 a.m., the administrator said all staff should know not to store clean linen with dirty barrels. The administrator said dirty barrels were to be stored in the shower room when not used. The administrator said the ADON/DON were responsible to ensure staff knew where to store dirty barrels. The administrator said clean linen next to dirty barrels could lead to cross contamination. Record review of the facility policy titled, Infection Control, dated October 2018 indicated, This facility infection control policies and practice are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. #1 the facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and to the public. #4 all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Record review of the facility policy titled, New Linen, Clean Linen and Soiled Linen Storage, dated 9/5/2017 indicated, Clean linen should be stored in a clean ventilated area. Soiled linen inside the facility should be placed in a soiled linen barrel with a lid . and should be stored in the soil utility room. 3. Record review of Resident #6's face sheet, dated 04/17/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included local infection of the skin, atrial fibrillation (irregular heart rate), and heart failure (heart muscle does not pump blood as well as it should). Record review of Resident #6's quarterly MDS, dated [DATE], indicated she was usually understood and usually understood others. Resident #6 had a BIMS score of 9, which indicated she had moderate cognitive impairment. Resident #6 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing. Resident #6 was totally dependent on transfers and toileting. The MDS indicated Resident #6 had 3 unstageable pressure injuries presenting as deep tissue injury and was receiving pressure ulcer/injury care treatment. Record review of Resident #6's comprehensive care plan, dated 3/22/23, indicated Resident #6 had stage 3 pressure ulcers to right leg and right heel with goals for the ulcers to remain free from infection and show signs of healing. The care plan interventions included to administer treatments as ordered and to monitor for effectiveness. Record review of Resident #6's order summary dated 4/17/23, indicated she had the following orders: *Cleanse right calf with normal saline/wound cleanser, pat dry, apply calcium alginate, cover with dry dressing daily and as needed. *Cleanse right heel with normal saline/wound cleanser, pat dry, apply xeroform, cover with dry dressing daily and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 24 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 04/17/23 at 3:12 p.m., LVN A entered Resident #6's room to provide wound care to her right calf and heel. LVN A washed her hands and donned gloves. LVN A removed Resident #6's dressing from her right calf and heel. LVN A placed Resident #6's leg on the pillow with the open wounds touching the pillow. LVN A picked up Resident #6's leg off the pillow and the pillow was visibly soiled with blood from the wounds. LVN A proceeded to cleanse the wound with wound cleanser. After cleaning the wounds, LVN A placed Resident #6's leg back on top of the soiled pillow. LVN A picked up Resident #6's leg off the pillow and applied the dressing to her right heel. LVN A failed to ensure the wound stayed cleaned prior to applying the dressing. LVN A placed Resident #6's leg back on the soiled pillow to remove gloves and perform hand hygiene. LVN A put on gloves and picked up Resident #6's leg off the pillow and applied a clean dressing to the wound to her right calf. LVN A failed to cleanse the wound with wound cleanser prior to applying the clean dressing. LVN A said she was hired a week and half ago and her competency for performing wound care had not been completed. LVN A said Resident #6 was not able to hold her leg up during the wound care, and she did not think to ask someone for assistance. LVN A said not providing proper wound care placed Resident #6 at risk for infection. During an interview on 04/19/23 at 09:50 a.m., the ADON said she expected LVN A to have asked for assistance from an aide or a nurse in holding Resident #6's leg up when she provided wound care. The ADON said LVN A could have also had placed a clean barrier on top of the pillow. The ADON said she expected LVN A to have cleaned the wounds again prior to applying the clean dressing as the wounds were considered contaminated. The ADON said not cleaning the wound prior to completing the treatment caused Resident #6 to be at risk for infection. During an interview on 04/19/23 at 10:10 a.m., the DON said she expected LVN A to have had used a barrier between Resident #6's leg and the pillow or she should have had asked for someone for assistance in holding Resident #6's leg up. The DON said she expected LVN A to clean Resident #6's wounds before applying the clean dressing. The DON said not cleaning the wound again after it became contaminated placed Resident #6 at risk for infection. During an interview on 04/19/23 at 10:45 a.m., the administrator said she expected wound care to be done as per physician orders. The administrator said she expected LVN A to have asked for assistance when she provided wound care to Resident #6 and not cleaning the wound prior to applying the clean dressing placed Resident #6 at risk for infection. Record review of LVN A's Treatment Nurse Competency Check Off, dated 4/17/23, indicted skill being met. Record review the facility's treatment and nurse competency check off indicated .18. If any area was contaminated, start over . 4. Record review of Resident #3's face sheet, dated 04/20/23, indicated a [AGE] year-old male who admitted to the facility on [DATE], with diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture), diabetes (condition that affects the way the body processes blood sugar), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), essential hypertension (high blood pressure). Record review of Resident #3's quarterly MDS assessment, dated 03/10/23, indicated he was usually understood and usually understood others. Resident #3 had a BIMS score of 15 which indicated he had intact cognition. Resident #3 required extensive assistance with bed mobility and dressing and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 25 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some totally dependent on staff with transfers, toileting, and bathing. Resident #3 was always incontinent of bowel. Record review of Resident #3's comprehensive care plan, revised on 02/13/23, indicated he had an ADL self-care performance deficit related to paraplegic (paralysis of the legs and lower body). The care plan interventions included Resident #3 required assistance of 2 for toileting needs, especially bowel movements. During an observation and interview on 04/17/23 at 3:19 p.m., CNA K and CNA O entered Resident #3's room and provided incontinent care because he had a bowel movement. CNA K removed Resident #3's pants and placed them in the trash bag. CNA K removed her gloves and reapplied clean gloves. CNA K failed to perform hand hygiene in between glove changes. CNA K unfastened Resident #3's brief and obtained disposable wipes. CNA K cleaned Resident #3's perineal area. CNA K removed Resident #3's soiled brief and applied a clean brief. CNA K used the dirty gloves to apply barrier cream to Resident #3's buttocks and to apply the clean brief. CNA K removed her gloves and reapplied clean gloves. CNA K failed to perform hand hygiene after removing her dirty gloves. CNA K completed Resident #3's incontinent care, removed her gloves and performed hand hygiene. CNA K said she should have performed hand hygiene in between glove changes. CNA K said she should have changed her gloves after she cleaned Resident # 3's perineal area, before applying the barrier cream and the clean brief. CNA K said she was responsible for providing proper incontinent care. CNA K said not providing proper incontinent care placed Resident #3 at risk for infection. During an interview on 04/19/23 at 09:50 a.m., the ADON said she expected CNA K to change her gloves when going from dirty to clean and again when she applied the barrier cream to Resident #3. The ADON said CNA K should have performed hand hygiene between glove changes. She said not changing her gloves and not performing hand hygiene in between glove changes placed Resident #3 at risk for infection. During an interview on 04/19/23 at 10:10 a.m., the DON said she expected CNA K to have changed her gloves when going from dirty to clean and she should have performed hand hygiene in between gloves changes when she provided incontinent care to Resident #3. The DON said not changing her gloves or performing hand hygiene placed Resident #3 at risk for infection. The DON said she was responsible for ensuring the staff was providing proper incontinent care and following the infection control policy. During an interview on 04/19/23 at 10:45 a.m., the administrator said she expected staff to change their gloves when going from dirty to clean and perform hand hygiene in between glove changes. The administrator said not doing so was an infection control issue and placed Resident #3 at risk for infection. The administrator said the administrative nurses were responsible for ensuring nursing staff provided proper incontinent care and performed hand hygiene. Record review of CNA K's perineal care competency evaluation, dated 4/4/23, indicated skill being met. Record review of the facility's policy titled, Perineal Care, revised February 2018, indicated .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition 10. remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly or use hand sanitizer. 12. Put on clean gloves and apply protective ointment if needed and clean brief . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 26 of 27 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy, titled Handwashing/Hand Hygiene, revised August 2019, indicated .This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . m. after removing gloves . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 27 of 27