Inspection·January 11, 2023

F 0655 resident's wishes to not be honored. The ADMN stated what led to failure was staff need more education. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled; Care Plans-Baseline dated December 2016 revealed; A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission . The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop and interdisciplinary person-centered care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 2 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 4 (Resident #32, #3, #8, and #12) of 11 residents reviewed for care plan completion. The facility failed to ensure Resident #32, Resident #3, and Resident #8 had a clear and updated comprehensive care plan specific to Code Status. The facility failed to ensure Resident #12 had a clear and updated comprehensive care plan regarding resident behaviors, interventions, and goals. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #32's electronic face sheet dated [DATE] revealed resident was an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, Psychotic Disorder, and Dementia. Review of Resident #32's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 09 (moderate cognitive impairment). Record review of Resident #32's electronic physician orders dated [DATE] revealed: Do Not Resusicate order date [DATE]. Record review of Resident #32's Comprehensive Care Plan initiated on [DATE] and revised on [DATE] revealed: Focus: Code Status: Full Code [DATE] Resident is now a DNR. Goal: Her wishes will be respected. Interventions: Should her heart and respirations cease, she will be given CPR, EMS activated, and she would be transported to EMH ER. (Changed: She will not be given CPR. Comfort measures will be provided, and EMS will not be activated. Record review of Resident #3's electronic face sheet dated [DATE] revealed resident was a [AGE] year-old female who was admitted on [DATE] with diagnoses that included: COVID-19, Psychotic Disorder, Dementia, Depression, and Diabetes. Review of Resident #3's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 11 (moderate cognitive impairment). Record review of Resident #3's electronic physician orders dated [DATE] revealed: DNR, order date [DATE]. Record review of Resident #3's Comprehensive Care Plan initiated on [DATE] and revised on [DATE] revealed: Focus: Code Status: Full Code [DATE] Resident is now a DNR. Goal: Her wishes will be respected. Interventions: Should her heart and respirations cease; CPR will be started, and EMS activated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 3 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She may change her mind at any time and will be given information regarding pros and cons of choices. [DATE] Changed: Should heart and respirations cease CPR will not be started and EMS will not be activated. Record review of Resident #8's electronic face sheet dated [DATE] revealed resident was a [AGE] year-old female who was admitted on [DATE] with diagnoses that included: fracture of left femur, Alzheimer's, COVID-19, Depression, and Dementia. Review of Resident #8's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 00 (severe cognitive impairment). Record review of Resident #8's electronic physician orders dated [DATE] revealed: DNR, order date [DATE]. Record review of Resident #8's Comprehensive Care Plan initiated on [DATE] and revised on [DATE] revealed: Focus: Code Status: Full Code to DNR. Goal: Her wishes will be respected. Interventions: Should her respirations cease and heart stops, CPR will be started, and EMS activated. (Changed) DNR. Should heart stop and respirations cease she will not have CPR started and EMS will not be activated. Record review of Resident #12's electronic face sheet dated [DATE] revealed resident was a [AGE] year-old female admitted on [DATE]with diagnoses that included: high blood pressure, altered mental status, Schizoaffective disorder, Anxiety, Major Depressive Disorder and chronic pain. Record review of Resident 12's quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS of 8 (moderate cognitive impairment). Record review of Resident #12's Comprehensive Care Plan initiated on [DATE] and revised on [DATE] revealed: Focus: the resident has a behavior problem attention seeking r/t needing assist changes to poc ie: when COVID boosters were given she refused then a few days later requested one. She got her knee-high teds a few days later quit wearing them because she says they roll down and hurt her and then requested thigh hi ones. Goal: The resident will have fewer episodes of needy top behavior by review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, intention. Stop and talk with him/her as passing by. Explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Erase any indication of the resident progress slash improvement in behavior. During an interview on [DATE] at 1:51 PM, the DON stated she responsible for care plans. The DON stated her expectations for comprehensive care plans was person centered and include resident needs. The DON stated when a goal was changed, she doesn't close out the goal she just adds to previous goal. The DON stated that if she were to close the goal the information would be deleted and lost forever. The DON stated she could see how combined goals could be confusing and not be measurable. The DON stated hopefully it would not be an issue for residents. The DON stated, needy behaviors would be pushing call lights and then when nurse got to room saying oh did I do that. The DON stated she supposed the words needy behavior could be derogatory and was probably not a measurable goal. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 4 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the effect on a resident could have offended someone. The DON would not provide a reason for the failure. During an interview on [DATE] at 2:29PM, the ADMN stated her expectation of comprehensive care plan was to be completed in timely manner, detailed, goal should be attainable and measurable. The ADMN stated the DON was responsible for completing comprehensive care plans. The ADMN stated she was not sure what needy behaviors were, after reading Resident #12's care plan. She stated the behaviors listed would not be needy behaviors but normal behaviors of residents in the facility. The ADMN stated the effect on resident would be a resident might feel ashamed and not want to ask for help. The ADMN stated when a goal was completed or changed it should be ended and a new goal should be initiated. The ADMN stated the combined goals were confusing to read and not understandable. The ADMN stated what led to failure was staff need more education. Record review of facility policy titled, Care Plans, Comprehensive Person- Centered dated [DATE] revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 5 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, Interviews, and record reviews, the facility failed to ensure the environment was free of accident hazards 2 of 2 locations (200 hall cart and 200 hall closet) ) reviewed for hazards. Residents Affected - Some The facility failed to ensure that cleaning supplies were stored properly, 200 hall cart and 200 hall closet. This failure could expose residents to harmful chemicals. Findings included: During observation on 01/11/23 at 9:00 AM, the PPE 200 hall cart had an open aerosol disinfectant spray can, and spray bottle containing disinfectant on top of cart and unsecured. During an interview on 01/11/23 at 9:10 AM, CNA-G stated the chemicals were not to be left out for easy access to residents. She stated it could have been hazardous to residents and could have been fatal. During observation on 01/11/ 23 at 9:12 AM, the housekeeping 200 hall closet with chemicals and spray bottle disinfectants were stored in an unlocked closet. During an interview on 01/11/23 at 9:13 AM, HK-C stated he did not know why the disinfectant chemicals were on the PPE cart. HK-C stated all chemicals should be kept behind locked compartments, cabinets and/or closets when not in use. HK-C stated, the negative impact on residents would be harmful and hazardous for residents. HK-C stated the failures were with him as HK supervisor, and his expectations were for all chemicals to be locked. During an interview on 01/11/23 at 9:21 AM, HK-D stated, the aids and/or nurses must be getting the cleaning solutions out and not locking them up for easy access. During an interview on 01/11/23 at 9:25 AM, the Admin stated HK-C informed her of cleaners and disinfectant being left out on the cart as well as the unlocked HK closet. She stated her staff did not pay attention to what they were doing in not storing them in a locked room. She also stated, the chemicals should have never been left out, and could harm to residents if they drink it, causing even more health issues. She stated, the chemicals not being behinds locked compartments or doors was ultimately her responsibility and that was where the failure occurred. Her expectations were for the halls and HK closets to be closely monitored and inspected with staff needing increased trainings. During an interview on 01/11/23 at 9:46 AM, the DON stated chemicals were to be stored behind locked cabinets and closets at all times when not in use. She stated, the failure was having chemicals out that would harm the residents, in many ways, such as respiratory or vomiting issues. Record Review of facility policy Location of Hazardous chemicals, with a revised date of February 2013, revealed; Policy Statement: Locations where hazardous chemicals and/or materials are used, stored or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 6 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 transported are identified and marked. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: 1. Residents Affected - Some Hazardous chemicals and/or materials are maintained in the following locations: ALL Hazardous Material-Housekeeping Storage-stays locked . 4. The Program Coordinator is responsible for touring the premises at least quarterly to determine whether or not hazardous chemicals and/or materials are stored in unmarked areas. A written report of the results of the inspection is completed and filed in the business office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 7 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on interviews and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the Registered nurses, Licensed practical nurses or licensed vocational nurses or Certified nurse aides directly responsible for resident care per shift for 1 of 1 Staffing Log reviewed. Residents Affected - Many The facility failed to ensure the Direct Care Nursing/Staff Daily Log dated 01/10/2023 was completed with no CNA hours for the 2pm- 10pm shift and no RN, LVN or CNA hours for the 10pm-6am shift. The facility failed to ensure the Direct Care Nursing/Staff Daily Log dated 01/11/2023 was completed with no RN, LVN or CNA hours for the 2pm- 10pm shift and no RN, LVN or CNA hours for the 10pm-6am shift. This failure could place residents, their families, and visitors at risk of not having the staffing information readily accessible for review, residents and visitors are not able to know how many staff are currently working to provide care on all shifts. Findings Included: Record review on 01/10/2023 of Direct Care Nursing/Staff Daily Log dated 01/10/2023 revealed no documented CNA hours for the 2pm- 10pm shift and no RN, LVN or CNA hours for the 10pm-6am shift. Record review on 01/11/2023 of Direct Care Nursing/Staff Daily Log dated 01/11/2023 revealed no documented no RN, LVN or CNA hours for the 2pm- 10pm shift and no RN, LVN or CNA hours for the 10pm-6am shift. During an interview on 1/11/2023 at 1:51PM, the DON stated the Direct Care Nursing/Staff Daily Log should have been updated by the charge nurse at the beginning of each shift. The DON stated what led to failure was that no one double checked to make sure the logs were completed . The DON stated her expectation was the Direct Care Nursing/Staff Log should have been completed at beginning of every shift with RN, LVN and CNA hours. During an interview on 1/11/2023 at 2:29 PM, the ADMN stated the Direct Care Nursing/Staff Daily Log should have been completed at the beginning of each shift by charge nurse. The ADMN stated what led to failure of not being completed, was staff being too busy. The ADMN stated the effect on residents could have been facility short staffed and residents and family hollering about not having enough staff. The ADMN did not provide a facility policy for posting daily staffing hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 8 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 4 (Resident #9, Resident #32, Resident #3, and Resident #29) of 16 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #9's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 2. The facility failed to ensure Resident #32's PRN Vistaril (medicine used to treat the symptoms of anxiety) and Diazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 3. The facility failed to ensure Resident #3's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 4. The facility failed to ensure Resident #29's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. These failures could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Resident # 9 Record review of Resident #9's electronic face sheet dated 01/11/2023 revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, fracture of right wrist, Prostate Cancer, atherosclerotic heart disease of Native coronary artery without angina pectoris, transient ischemic attack, neuropathy, hypertension and anemia. Review of Resident #9's MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS score of 10(moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 7 days out of the last 7 days of review period and opioids the last 6 days of the last 7 days of review period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 9 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 0758 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's electronic physician orders dated 01/11/2023 revealed: Lorazepam tablet .5mg give 1 tablet by mouth every 4 hours as needed for Prophylaxis for 6 months. With a start date of 10/21/2022 and an end date of 4/21/2023 and Lorazepam tablet .5mg give 2 tablets by mouth every 4 hours as needed for Prophylaxis for 6 months. With a start date of 10/21/2022 and an end date of 4/21/2023 Residents Affected - Some Review of Resident #9's physician progress notes from October 2022- January 2023 revealed no documented rationale for the continued provision of lorazepam. Resident #32 Record review of Resident #32's electronic face sheet dated 01/11/2023 revealed resident was an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, Psychotic Disorder, and Dementia. Review of Resident #32's MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS score of 09 (moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 7 days out of the last 7 days of review period, Antipsychotic medication 7 days out of the last 7 days of review period, Antidepressant medication 7 days out of the last 7 days of review period and opioids the last 6 days of the last 7 days of review period. Record review of Resident #32's electronic physician orders dated 01/11/2023 revealed: Diazepam 10MG/ML give 0.5 ml by mouth every 4 hours as needed for Anxiety with a start date of 09/15/2022, Diazepam 10MG/ML gel give 1ml apply to wrist topically every 4 hours as needed for Anxiety for 6 months with a start date of 11/02/2022 and an end date of 05/02/2023, and Vistaril oral capsule 50 MG give 1 capsule by mouth every 4 hours as needed for Anxiety for 6 months with a start date of 11/02/2022 and an end date of 05/02/2023 Review of Resident 32's physician progress notes from November 2022- January 2023 revealed no documented rationale for the continued provision of lorazepam. Resident #3 Record review of Resident #3's electronic face sheet dated 01/11/2023 revealed resident was a [AGE] year-old female who was admitted on [DATE] with diagnoses that included: COVID-19, Psychotic Disorder, Dementia, Depression, and Diabetes. Review of Resident #3's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 11 (moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 7 days out of the last 7 days of review period, Antipsychotic medication 7 days out of the last 7 days of review period, Antidepressant medication 7 days out of the last 7 days of review period and opioids the last 7 days of the last 7 days of review period. Record review of Resident #3's electronic physician orders dated 01/11/2023 revealed: Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 2 hours as needed for ANXIETY for 6 Months with a start date of 10/03/2022 and an end date of 04/03/2023 and Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 2 tablet by mouth every 2 hours as needed for ANXIETY for 6 Months with a start date of 10/03/2022 and an end date of 04/03/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 10 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #3's physician progress notes from October 2022- January 2023 revealed no documented rationale for the continued provision of lorazepam. Resident #29 Record review of Resident #29's electronic face sheet dated 01/11/2023 revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: COVID-19, Psychotic Disorder, Dementia, Depression, and Diabetes. Review of Resident #29's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 11 (moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 7 days out of the last 7 days of review period, Antipsychotic medication 7 days out of the last 7 days of review period, Antidepressant medication 7 days out of the last 7 days of review period and opioids the last 7 days of the last 7 days of review period. Record review of Resident #29's electronic physician orders dated 01/11/2023 revealed: Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 2 hours as needed for ANXIETY for 6 Months with a start date of 10/03/2022 and an end date of 04/03/2023 and Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 2 tablet by mouth every 2 hours as needed for ANXIETY for 6 Months with a start date of 10/03/2022 and an end date of 04/03/2023. Review of Resident #29's physician progress notes from October 2022- January 2023 revealed no documented rationale for the continued provision of lorazepam. During an interview on 01/11/2023 at 2:30 PM, the DON stated all PRN psychotropic medications should have a 14 day stop date. She stated Lorazepam, Vistaril, Diazepam used as a PRN medication were all medications that required a stop date. She stated every 14 days the facility should reevaluate the need for these medications and request a new order if needed. She stated these orders were just somehow overlooked and she does not know why the failure occurred. DON stated she was responsible for overseeing the orders but the floor nurses enter the orders and sometimes they forget to put the stop date. She stated these four residents were on hospice services and said that could be the reason they were missed. The DON stated this failure could lead to residents receiving unnecessary medications. Review of facility policy titled, Antipsychotic Medication Use, revised December 2016 revealed: Policy Statement: antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reductions and re-review. Policy Interpretation and Implementation: .13. Residents will not receive PRN doses of psychotropic medication unless the medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders for psychotropic medication beyond 14 days requires that the petitioner document the rationale for the extended order. The duration of the PR in order will be indicated in the order. 15. PRN orders for anti-psychotic medications will not be renewed beyond 14 days unless the health care practitioner has evaluated the resident for the appropriateness of that medication. 16. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including anti-psychotic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 11 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended by LVN A and LVN B. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: During observation on 01/10/23 9:42 AM of the unlocked medication cart , revealed: Prescription and OTC eye medication in the top left drawer, Insulin meds, syringes and scissors were in the top right drawer. The second left drawer of the cart contained blister packs of prescription medications, and the third left drawer contained overflow medications cards and over the counter liquid medications. The second right drawer contained narcotics in the single locked drawer. The third right drawer contained OTC medications and the fourth right drawer contained wound care supplies, such as gels, sprays, tape and gauze. All unlocked drawers were easily accessible. During an interview on 01/10/23 at 9:56 AM, LVN-A stated she was nervous and, in a hurry, while performing wound care in a resident's room and forgot to lock the medication cart. LVN-A stated, this cart contained all prescription and OTC meds for 15 residents that included, but not limited to: eye meds, stool softeners, antipsychotics, Insulins, BP Meds, Narcotics, OTC, and wound care meds/gels with supplies that included scissors. She stated the negative impact on residents would be the possibility of residents taking prescription meds or scissors and could lead to a bad impact which were the failures. LVN-A stated her Expectation was for the med cart to be locked and secured at all times when not in use or monitored. During observation and interview on 01/10/23 at 10:04 AM, LVN-A left cart #1 unlocked a second time and stated she was nervous due to surveyors in the facility. During observation on 01/10/23 at 3:42 PM, LVN-B checked resident BS and left medication cart #1 in hallway unlocked while in resident room and accessible to residents. At 3:45 PM, LVN-B left medication cart open a second time to give the resident her medication. At 3:50 PM, LVN-B left unlocked a third time, medication cart #1 to retrieve sanitizing wipes. This cart #1 was observed a third time, unsupervised and unlocked. During an interview on 01/10/23 at 3:53 PM, LVN-B stated she was unaware she had left the cart unlocked and unattended. She stated the negative impact were that residents or visitors walking by an unlocked cart could be a safety issue, leading to possible drug diversion. She stated, this cart contained prescription meds for 15 residents, such as antipsychotics, BP, stool softeners, diabetic, narcotics, and wound care meds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 12 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/11/23 at 9:31 AM, the Admin stated the charge nurses were responsible for the med carts as well as the DON. She stated the negative impact to residents could have been something harmful being ingested. She stated, if staff were going to be out of sight of the cart, it should be locked and secure. She felt the failure was the nurse was being too comfortable. Her expectations were for the cart to be locked. Residents Affected - Some During an interview on 01/11/23 at 9:54 AM, the DON stated, she was aware the unlocked carts had been found open and the nurses had been previously trained on that. She stated the responsibility was the nurse who takes over the keys from previous nurse. She also stated, the failure occurred with the nurses just getting busy, and forgetting to push the lock button. Her expectations were to train and Inservice those nurses. Record Review of the facility's policy, titled Storage of Medications, revised April 2007, revealed: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes.) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 13 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 4(DS H, DS I, DS J, and DS K) of 8 dietary staff reviewed for Food Handler's certificates. The facility failed to ensure that dietary staff DS H, DS I, and DS K who prepared meals in the kitchen and served cooked food to residents were working with current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses due to lack of dietary staff training. Findings included: Record review of DS H's employee file revealed a hire date of 10/12/18 and expired food handler's certification. Record review of DS I's employee file revealed a hire date of 05/11/19 and expired food handler's certification. Record review of DS J's employee file revealed a hire date of 03/25/22 and expired food handler's certification. Record review of DS K's employee file revealed a hire date of 08/07/22 and no proof of food handler's certification. During an interview on 01/10/23 at 3:10 PM, the DM stated that everyone should have a food handler certification. The DM acknowledged that Dietary Staff were required to have Food Handler Certifications. The DM stated what led to failure was dealing with fog brain from COVID and she had not kept up with everyone's food handler certificate. Record review of Job Description for Cook without a date revealed: Job knowledge: Hazards of improper food handling, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 14 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. Residents Affected - Many The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure kitchen equipment was clean. These failures could place residents that eat meals that are prepared in the kitchen at risk for food borne illnesses. Findings included: Observation on 01/09/2023 between 10:20 AM and 11:30 AM revealed: Pantry 1. One opened tub of vanilla cream icing with an open date of 12/5, with a manufacture label that stated refrigerate 1 week after opening. 2. One dented can of Cream of Celery soup. 3. One dented can of cream of mushroom soup. 4. One opened box containing 6 1-gallon bottles of bleach. 5. One opened bottle of vegetable oil blend not labeled with an open or use by date. 6. Two opened bottles of Worcestershire sauce that had not been wiped that had brown substance dripped down the sides. 7. One opened bottle of liquid butter that was greasy to touch and had drippings down the side. 8. One opened bottle of corn oil that had a brown substance on side of bottle that appeared to be peanut butter. 9. One opened bottle of syrup had a brown substance on side of bottle that appeared to be peanut butter. Refrigerator 1. A plastic container containing white cheese that did not have a label identifying the item, or an open or use by date. 2. An opened bag of leaf lettuce not labeled with description or date, lettuce was black, slimy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 15 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 and wilted. Level of Harm - Minimal harm or potential for actual harm 3. An opened bag of mixed lettuce greens that was not sealed and not labeled with an open or use by date. Residents Affected - Many The gas stove appeared to not have been cleaned. There were thick black crusty substance on stove top and burners, food crumbs were all over the stove top. Observation on 01/10/23 at 3:10 PM revealed the gas stove had not been cleaned. There were thick black crusty substance on stove top and burners, food crumbs were all over the stove top. During an interview on 01/10/23 at 3:10 PM, the DM stated the gas stove should have been wiped down after each use and deep cleaned monthly. The DM stated she did not know when the last time the stove had been cleaned and that it needed to be cleaned . The DM stated what led to failure was that staff had been busy and working long hours due to cover for staff that were out with COVID. The DM stated unopened items should have been labeled with a receive date if did not have a use by manufacture printed. The DM stated open items should have had an open date or expiration dated. The DM stated that opened bottles should have been wiped down after each use; bottles should not have had greasy substance or dried liquid on sides. The DM stated that dented cans should have been removed from the shelves and not be used. The DM stated she must have not noticed the dented cans. The DM stated what led to failure of items not labeled with dates or description was that staff were in hurry and not paying attention. During an interview on 1/11/23 at 2:29 PM, the ADMN stated the DM was ultimately responsible for maintaining kitchen. The ADMN stated her expectation was that kitchen was remained clean, sanitized and food be stored properly. The ADMN stated failures in kitchen could have affected residents by causing residents minimal to severe harm. The ADMN stated what led to failure was everyone was tired from having to work extra the past 4 months to cover for each other, and things were not getting done properly. Review of CMS form 672 date 1/09/2023 revealed that 31 of 31 residents eat out of kitchen. Review of facility policy titled, Dietary Reminder dated 11/3/21 revealed: Remember to label everything with contents and/or date open. Be sure everything is sealed, covered well or zipped in a zip bag. Wipe any spills off containers with sanitizer cloth before returning it to storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 16 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 4 of 10 staff (Administrator, DON, LVN A, and CNA L) reviewed for infection control. Residents Affected - Some The facility failed to ensure staff (Administrator, DON, LVN A, and CNA L) wore appropriate face coverings correctly according to manufactures specifications while providing direct care services. The facility failed to ensure no cross-contamination occurred when LVN A failed to wash or sanitize hands prior to, during, or after performing wound care on Resident #16. These failures could place residents at risk of development and transmission of communicable diseases and infections. Findings included: During an observation on 01/09/2023 at 10:00 AM, CNA L was assisting Resident #9 who was not COVID positive by pushing her wheelchair in the hallway wearing a surgical face mask with her nose uncovered. CNA L raised the mask over her nose, then pulled it back below her nose when she entered Resident #9's room. CNA L assisted Resident # 9 to her bed. CNA L then exited the room and went to the nurse's station where she applied an N-95 mask. During an observation and interview on 01/09/2023 at 10:05 AM, the DON was observed wearing an N-95 mask with straps cut and tied behind her ears and the Administrator was observed wearing an N-95 mask with one strap hanging below her chin and one strap over her head. The Administrator stated the facility was in a COVID outbreak with 1 COVID positive resident. She stated all staff were wearing N-95 mask while in outbreak. During an observation on 01/10/2023 between 08:30 AM and 09:30 AM, LVN A was observed leaving the nurses station, walking down the hall, and entering Resident #16's room to perform wound care on Resident #16, with an N-95 mask pulled below her nose. LVN A was observed performing wound care on Resident #16 with her mask down below her nose. LVN A was then observed during an interview with her mask down below her nose. During an observation on 01/10/2023 at 9:00 AM, LVN A entered Resident #16's roomto perform wound care on Resident #16 with gloves on without performing hand hygiene. She closed the door with gloved hands and repositioned Resident #16. LVN A removed the dressing from the wound, disposed of in the trash, then cleansed the wound with gauze that she grabbed from out of her pocket. LVN A removed soiled gloves and did not have another pair. She exited the room without performing hand hygiene and went to the medication cart in the hallway. She donned gloves with no hand hygiene, entered resident's room, closed the door with gloved hands, grabbed a dressing from her pocket and placed it on Resident #16's wound. LVN A then donned gloves and exited the room without performing hand hygiene. During an interview on 01/10/2023 at 9:30 AM, LVN A stated poor wound care and not wearing a mask properly could have a very negative impact on residents and spread infection. She stated she was just nervous because she was being observed. She stated she knew how to perform wound care and that it was not a sterile procedure unless it was ordered to be sterile. She stated she did not know how to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 17 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 properly wear a N-95 mask. She was unaware of if she had received any training on proper placement of a mask. During an interview on 01/10/2023 at 10:00 AM, CNA L denied wearing a surgical mask and wearing it improperly. She stated she had been trained on how to wear a mask and to wear an N-95 due to having COVID positive resident. During an interview on 01/11/2022 at 09:30 AM, the Administrator stated her expectation was for all staff to wear N 95 mask in building due to positive COVID. The ADMN stated mask should not be altered in any way, that altered mask lessen the value of mask ability to seal correctly on the face. The ADMN stated staff should not have been wearing altered mask. The admin stated mask should always be worn properly and should cover the nose to provide a good seal. The ADMN stated the effect on residents was increased chance of getting COVID. The ADMN stated she did not know what led to failure, that staff had been properly educated and it goes against policy. The ADMN stated management staff were responsible to ensure staff wore mask properly. She stated her mask was on improperly because she threw it on in a hurry upon surveyors' entrance. She stated she did not wear a mask in her office. The Administrator stated wound care should always be done with clean and sterile technique. She stated the nurse was just nervous about being observed. She stated not doing proper wound care could lead to infection. During an interview on 01/11/2023 at 10:00 AM, the DON stated her expectation was staff wear N95 mask when in the building. The DON stated staff should not be wearing altered mask. The DON stated staff should not cut mask to alter them, and that altering mask affects the seal of the mask. The DON stated N95 mask were in place to protect staff and residents from becoming ill. The DON stated it was everyone's responsibility to ensure staff wore mask properly. She stated she altered her mask because it gives her a headache. Record review of the facility wide in-service titled, Infection Control and COVID-19 dated 12/23/2022 presented by Administrator and DON revealed: The following areas of instruction were covered: .Importance of proper infection control and wearing of appropriate source control . Hand washing and washing of hands . Further review revealed in-service was signed by LVN A and CNA L. Record review on 01/11/2023 of N95 Respirator manufacturer instructions revealed: The respirators is approved only in the following configuration . Caution and Limitations: Failure to properly use and maintain this product could result in injury or death . Never substitute, modify, add, or omit parts . Fitting instructions: Pull the top headband to top back of head. Pull the bottom headband overhead and place around neck below ears. Record review of facility policy titled, COVID-19 PPE Source Control for Staff/Contract Employees/Volunteers, effective 08/01/2022 revealed: Policy Interpretation and Implementation: it is the policy of this facility that any staff/contract employees and volunteers providing services to residents in the facility or where they required and appropriate source control when needed. When county transmission levels are high the following PPE must be worn during all direct resident encounters and in hallways or any areas of the facility that is at high risk for COVID-19 transmission: 1. The use of an N95 mask. 2. The use of goggles/ and or face shield. 3. any other PPE that may be deemed necessary . during episode outbreak all the above (1-3) PPE will be worn at all times regardless of the county transmission level. Record review of facility policy titled, Standard Precautions, Revised October 2018 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676017 If continuation sheet Page 18 of 19 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 676017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Health Care Center 460 W Main St Ranger, TX 76470 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Policy Statement: standard precautions are used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions, non-intact skin and mucous membranes may contain transmissible infectious agents . Standard precautions include the following practices: 1. hand hygiene A. hand hygiene refers to hand washing with soap or the use of alcohol-based hand rub, which does not require access to water. B. Hand hygiene is performed with alcohol-based hand rub or soap and water. 1. Before or after contact with the resident; 2. before performing an aseptic task; 3. after contact with items in the residence rooms; and 4. after removing PPE. C. hands are washed with soap and water whenever 1. visibly soiled with dirt, blood, or bodily fluids 2. after direct or indirect contact with dirt, blood, or bodily fluids; 2. after removing gloves; 4. before eating and after using the restroom. Event ID: Facility ID: 676017 If continuation sheet Page 19 of 19