Health inspection·February 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/12/2023 at 11:11 AM Resident #192 stated it stinks in here and smelled like urine. It is making me sick to my stomach. He stated I tried to get up but can't with that mess in the floor (he pointed to the sheets/ pad on the floor in front of him). Observation on 02/12/2023 at 12:10 PM revealed the sheets and pad was still in the same place in Resident #192's room. There was still a urine odor in the room. Resident roommate was not in room. In an interview on 02/12/2023 at 12:15 PM CNA F stated she forgot to pick up the sheets in Resident #192's room and she did not know how long they had been on the floor in his room. She stated it had been approximately over an hour. She stated she would go and check on the sheets immediately. She stated when she changes any resident bed, she was to put the dirty sheets and pads in a garbage bag and tie the bag. She was to carry the bag to the dirty linen barrel. She also stated it could be unhealthy and not clean for dirty sheets to remain in a resident's room. She stated she did not know how it could affect a resident except being unpleasant from smelling strong urine odor. Record review of Resident #21's face sheet undated reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses chronic kidney disease ( a condition in which the kidneys are damaged and cannot filter blood as well as they should), essential hypertension ( abnormally high blood pressure that is not the result of a medical condition) and adult failure to thrive (had multiple chronic medical conditions- resulting in a downward spiral of poor nutrition, inactivity, depression and decreasing functional ability). Record review of Resident #21's Quarterly MDS assessment dated [DATE] reflected Resident had a BIMS score of 10 indicated his cognition is mildly impaired. Resident required assistance with all ADL's. Record review of Resident #21's Care Plan revised on 01/17/2023 reflected resident had a communication problem related to minimal difficulty with hearing when not in a quite environment. Resident had renal insufficiency related to kidney disease. Observation on 02/12/2023 at 10:49 AM in Resident #21's room revealed there was a strong urine odor. There were yellow-stained sheets near Resident #21's roommate's bed. In an interview on 02/12/2023 at 10:51 AM Resident #21 stated he had been smelling urine all night and it was making him sick to smell the urine. He stated he did ask a nurse, or someone who worked here to check the urine smell and the staff stated they would check it for him. Resident #21 stated the urine scent never got better. In an attempted interview on 02/12/2023 at 10:53 AM Resident #27 roommate of Resident #21 refused to answer any questions. In an interview on 02/12/2023 at 12:15 CNA F stated the sheets in Resident #21's room was there when she came on duty today. She stated she forgot to pick up the sheets on the floor. She stated it did smell like urine in that room. She stated the sheets did have a yellow stain on them. She also stated this could affect a resident from sleeping if there were a urine scent in the room. She stated it was the CNA's responsibility to make rounds and place the soiled linens in a plastic bag. She stated after placing them in plastic bag the linens were to be placed in dirty linen barrel. In an interview on 02/12/2023 at 1:30 PM LVN D stated the sheets in Resident #21's room was left in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 2 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there from the night shift. She stated she thought a CNA was entering Resident # 21's room to get the dirty sheets. She stated she was expected to report it to the CNA and follow-up to ensure the sheets were taken out of Resident #21's room. She stated it was nurses' responsibility to monitor CNA's duties. She stated if the sheets were in the room most of the night and the room smelled like urine it could affect the residents sleep and be very uncomfortable to be in that room smelling urine. She stated it could be a safety hazard and it was very unsanitary. In an interview on 02/13/2023 at 12:50 PM the DON stated the staff was expected to take a trash bag into residents' rooms whenever they are changing linens on beds. She stated the dirty linens were to be placed in the trash bag and carried to the soiled linen cart for the linens to be transported to laundry. She stated leaving linens on the floor had a potential of being a safety hazard. A resident could trip on the linens. She stated reason to remove the linens immediately was to prevent any urine odors in the room. She stated smelling urine odor for a long period of time would be unpleasant for a resident. She stated it was nurse supervisor responsibility to ensure the CNAs was following proper protocol of ensuring the rooms were sanitary. She stated the general housekeeping policy was the only policy the facility had relating to linens. In an interview on 02/14/2023 at 10:30 AM the Administrator stated all linens were expected to be placed in a trash bag when removed for a resident's bed and placed in dirty linen barrel. He stated if any type of linens or pads were placed on the floor with urine scent, this would be considered not sanitary and possibly hazard for a resident to trip over the linens. He stated this had potential of being very uncomfortable for residents to smell urine scent. He stated leaving anything soiled with urine or bm in a resident's room was not keeping the resident's room sanitary. He stated it was the nurse supervisor's responsibility to make rounds throughout the day and check the residents and the environment in residents' room. Record Review of Facility Policy of General Housekeeping (not dated) reflected odor control is achieved by prompt and proper care of residents and soiled linens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 3 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to accurately reflect the resident's status for 1 (#5) of 6 residents reviewed for assessments in that: Residents Affected - Few Resident #5 was prescribed hemodialysis treatment three times per week, and it was not reflected in her Quarterly MDS assessment. This deficient practice could affect residents who receive assessments and could result in improper care. The findings were: Review of Resident #5's electronic face sheet dated 02/14/2023 revealed she was re-admitted to the facility on [DATE] with diagnoses of End stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Anemia in chronic kidney disease (kidneys are damaged and can't filter blood the way they should), Dependence on renal dialysis (A treatment needed when your own kidneys can no longer take care of your body's needs), and Dementia (impaired ability to remember, think, or make decisions). Review of Resident #5's most recent Quarterly MDS assessment with an Assessment Reference Date of 01/01/2023 revealed she scored a 10/15 on her BIMS which indicated she was moderately cognitively impaired. Resident #5 was not coded to be on dialysis. Review of Facility Resident Matrix (CMS Form 802) dated 02/12/2023 reflected Resident #5 was not checked for Dialysis. Review of Resident #5's most recent comprehensive care plan with a revision date of 07/09/2018 reflected under Problem .has chronic renal failure related to End stage disease and needs hemodialysis related to renal failure. Review of Resident #5's most recent Comprehensive Care Plan with a revision date of 07/09/2018 revealed under Interventions .Dialysis every Tuesday, Thursday, and Saturday at 5:15am Dialysis . and encourage resident to go for the scheduled dialysis appointments three times per week. Review of Resident #5's Clinical Physician Orders dated 02/14/2023 revealed Dialysis every Tuesday, Thursday, and Saturday at 4:45am Dialysis .with a revision date of 05/27/2020, Check Arteriovenous shunt (an access point for hemodialysis) for signs and symptoms of infection or bleeding, feel left Arteriovenous fistula for thrill (buzzing sensation) and listen to bruit (sound of blood moving through fistula or graft site with stethoscope every shift, Remove pressure dressing from shunt site 4 hours after dialysis, and AV shunt to Left forearm restrictions: no heaving lifting, no blood pressure checks and no blood draws to Left arm. Review of Resident #5's Dialysis Communication Sheets for the dates of 02/02/2023 to 02/14/2023 revealed she had been attending Dialysis appointments. Observation on 02/12/2023 at 2:34pm of Resident #5 revealed she was resting in her bed with eyes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 4 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0641 closed. Observed Arteriovenous shunt to left upper arm. Level of Harm - Minimal harm or potential for actual harm Observation on 02/13/2023 at 8:34am revealed Resident #5 sitting up in her bed eating breakfast on her bedside table. Resident #5 stated people have been taking her clothing, her tops and replaced them with pants and she doesn't understand why. Resident #5 was observed clean and dressed appropriately for the weather, and a stack of clothing was sighted near her nightstand on top of a box. Residents Affected - Few Interview on 02/14/2023 at 9:42am with the MDS Nurse revealed the Quarterly MDS Assessment with an ARD of 01/01/2023 for Resident #5 with Dialysis marked No under Treatments was an oversight and she would unlock the assessment and correct it. The MDS nurse further stated checking No under Treatments to Dialysis for this resident would affect payment and the consequence to the resident would be Dialysis as a medical condition would not be reflected in the MDS. Interview on 02/14/2023 at 12:08pm with the DON revealed Care Plans should be updated when the resident has a change in condition, depending on what the change of condition is. The DON stated as an example, an altered mental status would need to be assessed by physician and would be acute and reported by staff, and an underlying condition, such as a Urinary tract infection, would be updated in Care Plan. The DON revealed when an MDS is inaccurate the consequences would be an inaccurate pay scale and an inaccurate level and may not reflect in the resident's Care Plan. DON further stated the facility follows procedure per the RAI (Resident Assessment Instrument). Interview on 02/14/2023 at 12:28pm with Resident #5 revealed she had gone to a dialysis appointment that the morning. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 5 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for two of eighteen residents reviewed for care plans. (Resident #9, and #43) A) The facility failed to ensure Resident #9's Comprehensive Care Plan reflected a revision of her plan of care after she had a significant weight loss. B) The facility failed to develop and implement Resident #43's Comprehensive Care Plan for contractures of her bilateral upper and lower extremities. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical well-being. Findings included: A) Review of Resident #9's Face sheet dated 02/14/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), History of falling, and congestive heart failure with hypertension (occurs when the heart muscle doesn't pump blood as well as it should; High blood pressure is a common condition that affects the body's arteries.) Review of Resident #9's Quarterly MDS dated [DATE] reflected Resident #9 was assessed to have a BIMS score of 14 indicating she was cognitively intact. Resident #9 was assessed to require extensive assist with ADLs. Resident #9 was further assessed to have a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of Resident #9's Comprehensive Care plan reflected a problem with the start date of 04/09/2018 reflected Resident #9 with the potential for nutritional problems related to impaired cognition and weight fluctuations related to the use of diuretics. Review of Resident #9's care plan reflected no plan of care for significant weight loss. Review of Resident #9's Weights reflected her weight on 12/12/2023 was 193 lbs. and her weight on 01/04/2023 was 181lbs. Weekly weights reflected a continued loss with a weight, with the resident weighing 177.2 lbs. on 01/09/2023. Record review of Resident #9's Dietary-Nutrition note dated 01/11/2023 reflected she had a significant weight loss of 7.2% in 30 days and 10.6% in 90 days. Interventions added related to weight loss were to increase house 2.0 supplement to 60 cc three times daily and continue appetite stimulant and for RD to monitor. Observation and interview with Resident #9 on 02/12/2023 at 11:40 AM revealed Resident #9 in room in bed. Resident #9 was alert but confused and did not answer questions appropriately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 6 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/14/2023 at 9:41 AM the MDS Coordinator stated she was responsible for revising the resident care plans. She stated after reviewing Resident #9's medical record that Resident #9 did have a significant weight loss and a change in care which should have been updated to her care plan to include her new weight loss interventions. She stated the care plan did feed into the POC (point of care) system that the CNAs have access to and by not updating her plan of care it could affect the residents care and the CNAs could miss interventions. B) Review of Resident #43's Face Sheet dated 02/13/2022 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior.) Osteoarthritis (Inflammation of one or more joints.), contractures of right and left hand, and contractures of right and left foot. Review of Resident #43's Quarterly MDS dated [DATE] reflected a BIMS was not conducted indicating Resident #43 had severe cognitive impairment. Resident #43 was assessed to require extensive to dependent assist for ADLs. Resident #43 was assessed to have upper and lower extremities range of motion limitations on both sides. Review of Resident #43's Comprehensive Care Plan reflected a problem area with the initiation date of 07/25/2022 for ADL self-care performance deficit related to muscle weakness, malaise and Dementia. Resident #43's Comprehensive Care Plan did not address her bilateral hand contractures, or her bilateral lower extremity contractures. Observation on 02/13/2023 at 9:51 AM revealed Resident #43 in room in bed. CNA H and CNA I were in the room to provide incontinent care. Resident #43's right hand was noted to have the middle, ring and pinky fingers curled into the palm of her right hand with her right index finger pushing into right her thumb. Observation of Resident #43's left hand revealed her index, middle, ring, and pinky fingers were curled toward her palm with her left thumb out. Resident #43 was further observed to have both lower extremities bent and pulled toward her trunk. Resident #43's legs remained in the fixed position during turning from side to side. Observation and interview on 02/13/2023 at 10:08 AM revealed the DON in Resident #43's room assessing Resident #43's upper and lower extremities. The DON stated Resident #43's hands and legs were contracted and stated she would get Resident #43's nails trimmed. The DON stated regarding treatment of Resident #43's contractures that she would have to look at the facilities policy to see what kind of interventions should be in place. In an interview on 02/14/2023 at 9:41 AM the MDS Coordinator stated she was responsible for developing resident care plans. She stated Resident #43's MDS indicated Resident #43 had limited range of motion to upper and lower extremities and should have had a care plan for the care of her limitations. She stated the care plan did feed into the POC (point of care) system that the CNAs have access to and by not updating her plan of care it could affect the residents care and the CNAs could miss interventions required for their care. In an interview on 02/14/2023 at 11:00 AM the DON stated that Resident #43 was evaluated and picked up by physical therapy for her contractures and should have had plan in place for her contractures already. Review of the Policy Care Planning provided by the facility on 02/14/2023 (undated) reflected a comprehensive person-centered care plan is developed and implemented for each resident to meet their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 7 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 needs. Baseline Care Plans to meet a Resident's immediate needs shall be developed within 48 hours. Comprehensive Care Plans are developed with 7 days of completion of the resident assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 8 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0679 Provide activities to meet all resident's needs. 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging independence in the community for 2 of 6 residents ( Resident #18 and Resident #21) reviewed for activities. Residents Affected - Few The facility failed to consistently provide activities for Resident #18 and Resident #21. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and a decreased quality of life. Findings include: A) Record review of Resident #18's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, unspecified whether hypoxia or hypercapnia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body. Trouble breathing and fatigue.), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (a condition of excessive worry about everyday issues and situations) and vascular dementia, unspecified severity, without behavioral disturbance (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain). Record review of Resident #18's Significant Change MDS assessment dated [DATE] reflected Resident had a BIMS score of a 10 indicated her cognition was mildly impaired. Resident #18 felt down, depressed, or hopeless 12-14 days during assessment period. She was tired or had little energy 12-14 days during assessment period. Resident indicated her Activity Preferences were the following: Very Important Activities: listen to music, do things with groups of people, do favorite activities, and participate in religious services or practices. Somewhat Important Activities: have books, newspapers, and magazines to read, keep up with the news, go outside to get fresh air when the weather is good. Resident #18 required assistance with ADL's. Record review of Resident #18's Quarterly MDS assessment dated [DATE] reflected resident had a BIMS score of 12 indicating her cognition was mildly impaired. Resident was feeling tired and had little energy 12-14 days (nearly every day). Resident felt down, depressed, or hopeless 7-11 days during assessment period. Resident required assistance with all ADL care. Record review of Resident #18's Comprehensive Care Plan revised on 12/23/2022 reflected Resident provided with in room activities of choice date initiated 03/13/2020. Resident had an ADL self-care performance deficit related to end stage disease, oxygen dependence, decreased mobility and impaired cognition. Resident was also assessed to use anti-anxiety medications related to end stage disease process with shortness of breath and anxiety. Resident used anti-depressant medication related to depression. Record review of Resident #18's Activity Annual Participation Review dated 01/06/2022 reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 9 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0679 Level of Harm - Minimal harm or potential for actual harm Resident does not attend group activities. Resident prefers to remain in room throughout the day resting and watching television. Resident received in room visits three times per week. Signed by Activity Director Record review of Activity list (not dated) of residents required in room activities reflected Resident #18 was on the list to receive in room activities three times per week. Residents Affected - Few Record review of In Room Participation Records reflected Resident #18 has not received in room activities on a consistent basis. In the records there was a date on 01/05/2023 when she was to receive in room activity, and she did not on that date. According to Resident #18's in room records she had not received any activity visits since 01/28/2023 thru 02/14/2023. Observation on 02/12/2023 at 11:30 AM revealed Resident #18 did not have any stimulation in her room. There was no music or television on in the room. In an interview with Resident #18 on 02/12/2023 at 11:30 AM she stated she was lonely and wanted to visit with someone. She did not respond to any other questions. In an interview on 02/12/2023 at 11:45 AM LVN D stated Resident #18 did not come out of her room. She stayed in bed. She stated she would benefit from in room visits from the activity department. She stated it would help her if someone would sit and talk to her, read to her, or do whatever she liked to do in the past. She stated she had not witnessed any activity staff in Resident #18's room. She stated someone from activities sometimes worked on weekends. In an interview on 02/12/2023 at 12:15 PM CNA F stated Resident #18 did not get out of her bed anymore. She stated it would be nice if someone from activities visited her. CNA F stated she had not seen anyone from activities in Resident #18's room. In an interview on 02/13/2023 at 11:30 AM Resident #18 stated she did have people to visit her sometimes but not anymore. Observation on 02/13/2023 at 1:00 PM Resident #18's room was quiet and there was not any stimulation, and the lights were turned was off when resident's room was entered. B) Record review of Resident #21's face sheet undated reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of adult failure to thrive (had multiple chronic medical conditions- resulting in a downward spiral of poor nutrition, inactivity, depression and decreasing functional ability), pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and localized edema (swelling due to an excessive accumulation of fluid at a specific anatomic site). Record review of Resident # 21's Quarterly MDS assessment dated [DATE] reflected Resident had a BIMS score of 10 indicated his cognition is mildly impaired. Resident required assistance with all ADL's. Record review of Resident #21's Care Plan revised on 01/17/2023 reflected resident had a communication problem related to minimal difficulty with hearing when not in a quite environment. Resident had little or no activity involvement related to disinterest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 10 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Activity Re-admit Activity assessment dated [DATE] reflected resident is a re-admit it is unknown if resident wish to participate in activities while in the home such as: in group, outings, one-one visits with staff or independent activities. It is unknown if activities needed to be modified to accommodate cognitive deficit or communication deficit. Assessment signed by the Activity Director. Review of Activity list (not dated) of residents required in room activities reflected Resident #18 was on the list to receive in room activities three times per week. Record review of In Room Participation Records reflected Resident #18 did not received in room activities on a consistent basis. The week of 01/01/2023 thru 01/07/2023 resident received one in room activity visit. Resident #18 did not receive in room activities from 01/26/2023 thru 02/14/2023. Observation and interview on 02/12/2023 at 10:51 AM revealed Resident #21 were watching television in his room. The lights were off, and he stated he the room was too dark and asked to turn on his lights. In an interview on 02/12/2023 at 10:51 AM Resident #21 stated he does worry a lot about his health. He stated it did help him when someone would come in and talk to him. He stated there was a lady that came in and would visit him, but he had not seen her over the past several weeks. He stated he was bored and became lonely sometimes. He stated he did not want a counselor. He stated he just wanted a friendly person to sit and talk to him about whatever he wanted to talk about at that time of visit. He stated he watched television, but that got old very fast. In an interview on 02/12/2023 at 12:15 PM CNA F stated Resident #21 did not get out of his bed due to his skin problems. She stated he liked to talk, and it would help him if someone came in his room and talked to him for a friendly visit. CNA F stated she had not seen anyone from activity department visiting with him. In an interview on 02/13/2022 at 3:30 PM Activity Assistant G stated she did not know where the in-room participation records were located at this time. She stated someone else had been documenting on the in-room records and she did not know what the person did with the records. She stated she did not know her name and did not know how to get in touch with her. She stated she had a list of residents receiving in room activities and she agreed that Resident #21 and Resident # 18 was on the list to receive in room activities three times per week. She stated the Activity Director explained in room activities to her before she went on leave of absence. She stated she would find the in-room participation records and bring them to the conference room. She stated the in-room activity record list was the current list of residents receiving in room activities for the past 9 - 11 months. Activity Assistant G did not know why the residents did not receive in room three times a week some weeks in January 2023 and February 2023. Observation on 02/13/2023 at 3:36 PM revealed a binder within room records written on the binder was sitting on the Activity Assistant G desk. In an interview on 02/13/2023 at 3:37 PM the Activity Assistant G stated she did not see the in room record book on her desk. She stated the Activity Director was out on personal leave at this time. She stated this was all the documentation she had for in room activities. In an interview on 02/14/2023 at 10:39 AM the Administrator stated if any residents were on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 11 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few list to receive in room activities it was expected these residents receive visits from activity staff three times per week. He stated the residents had potential of becoming bored and feel lonely. He stated each resident in the facility needed to be engaged in activities of their preferences. He also stated activities was beneficial with anyone with depression and activities could be a diversion for the resident if they were anxious or worried. He stated it was the Activity Department responsibility to ensure the residents are receiving in room activities. He stated he was the Activity Department Supervisor. He stated he was not aware the in-room activities were not being followed through by the activity staff. In an interview on 02/14/23 at 12:04 PM Activity Assistant G stated the activity staff visited in room residents three times per week. She stated if residents did not receive these activities three times per week there was a possibility the resident would not have anyone to talk to and become lonely. She also stated if a resident was already depressed or worried about something and did not have anyone to visit them it could affect their depression and they could become more worried. She stated it can make them lonelier if they did not receive in room activities and the residents did not leave their room. She also stated if received activities it would brighten their day and made the residents happy. She stated it was the activity staff responsibility to provide in room activities to residents. Record review of Facility Policy of In Room Activities (not dated) reflected For the residents who are unable to attend activities it is very important that we provide in room activities. All residents, particularly bedfast and those residents who are unable to participate in group activities will be visited at least three times a week. A log will be kept for those residents that are receiving in room activities. This log will be kept in a binder by the month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 12 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of eighteen residents reviewed with limited range of motion (Residents #43), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #43 was had interventions in place for her left- and right-hand contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of her left and right hands. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Record review of Resident #43's Face Sheet dated 02/13/2022 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior.) Osteoarthritis (Inflammation of one or more joints.), contractures of right and left hand, and contractures of right and left foot. Record review of Resident #43's Quarterly MDS dated [DATE] reflected a BIMS was not conducted indicating Resident #43 had severe cognitive impairment. Resident #43 was assessed to require extensive to dependent assist for ADLs. Resident #43 was assessed to have upper and lower extremities range of motion limitations on both sides. Record review of Resident #43's Comprehensive Care Plan reflected a problem area with the initiation date of 07/25/2022 for ADL self-care performance deficit related to muscle weakness, malaise and Dementia. Resident #43's Comprehensive Care Plan did not address her bilateral hand contractures, or her bilateral lower extremity contractures. Record review of Resident #43's EMR reflected no physical therapy evaluations or plans of treatment. Observation on 02/13/2023 at 9:51 AM revealed Resident #43 in room in bed. CNA H and CNA I were in the room to provide incontinent care. Resident #43's right hand was noted to have the middle, ring and pinky fingers curled into the palm of her right hand. with her right index finger pushing into right her thumb. Resident #43's fingernails on her right index finger and thumb were long and jagged with her right index fingernail pushing into her right thumb. Observation of Resident #43's left hand revealed her index, middle, ring, and pinky fingers were curled toward her palm with her left thumb out which had a long-jagged fingernail. Interview and Observation on 02/13/2023 at 10:02 AM revealed CNA H stated Resident #43's hands were contracted, and her hands should at least have wash cloths in them to prevent her nails from digging into her hands. CNA H stated the nurses were responsible for trimming the fingernail of residents who were diabetic and if the resident was not diabetic the nurse aides were responsible for trimming the resident's fingernails. CNA H stated she did not know if Resident #43 was diabetic. CNA H tried (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 13 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 0688 Level of Harm - Minimal harm or potential for actual harm to open Resident #43's right hand. Resident #43's right hand opened slightly to reveal all her fingernails were long. CNA H tried to open Resident #43's left hand and it would not open. CNA H stated Resident #43's fingernails were long, and they could cut into her hand causing sores and infections. CNA H further stated Resident's #43's hands should be cleaned daily, and her fingernails kept short. CNA H stated she did not know why Resident #43's hands and fingernails were not being treated. Residents Affected - Some Observation and interview on 02/13/2023 at 10:08 AM revealed the DON in Resident #43's room assessing Resident #43's hands. The DON stated Resident #43's hands were contracted and stated she would get Resident #43's nails trimmed. The DON stated regarding treatment of Resident #43's contractures that she would have to look at the facilities policy to see what kind of interventions should be in place. Review of Resident #43's Nursing progress note dated 02/13/2023 at 10:36 AM revealed Nails cut to bilateral hands, hands cleaned with soap and water and gauze rolls applied. Indentions noted to right hand from where resident keeps hand closed (nail), no open areas noted at this time. Review of Resident #43's Physical Therapy evaluation dated 02/14/2023 at 10:17 AM reflected Resident was evaluated, and treatment initiated for contracture management. In an interview on 02/14/2023 at 11:00 AM the DON stated that Resident #43 was evaluated and picked up by physical therapy for her contractures and should have had a plan in place for her contractures already. The DON stated the facility did not have a policy for contracture management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 14 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 provide respiratory care consistent with professional standards of practice for 1 of 2 residents (Resident #18) reviewed for oxygen therapy. Residents Affected - Few The facility failed to ensure the oxygen tubing and the humidifier had water in it and was changed on a weekly basis. The tubing and the humidifier were labeled 01/05/2023. This failure placed residents at risk of nose and throat discomfort, inadequate respiratory care, and infection control. The findings included: Review of Resident #18's (undated) face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure, unspecified whether hypoxia or hypercapnia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body. Trouble breathing and fatigue.), dependence on supplemental oxygen (treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems), other season allergic rhinitis (caused by nasals reaction to small airborne particles. In some people these particles also cause reactions in the lungs - asthma- and eyes - allergic conjunctivitis), and age-related physical debility (frail patients are at increased risk of decline because of illness). Review of Resident #18's quarterly MDS assessment dated [DATE] reflected resident had a BIMS score of 12 indicating her cognition is mildly impaired. Resident was feeling tired and had little energy 12-14 days (nearly every day). Resident did not exhibit any rejection of care. Resident required assistance with all ADL care. Resident had diagnosis of chronic respiratory failure. Resident was assessed to require Oxygen therapy. Review of Resident #18's Comprehensive Care Plan with start date 12/23/2022 and a completed date of 12/29/2022 reflected resident was a high risk for communicable respiratory infections. Resident had an ADL self-care performance deficit related to end stage disease, oxygen dependence, decreased mobility and impaired cognition. Resident had oxygen therapy related to respiratory failure. Resident will not have any signs or symptoms of poor oxygen absorption. Resident was also assessed to use anti-anxiety medications related to end stage disease process with shortness of breath and anxiety. Observation on 02/12/2023 at 11:30 AM in Resident #18's room revealed oxygen tank in her room. The oxygen tank was on, and the oxygen humidifier bottle was empty. The date on the humidifier bottle and the tubing was 01/05/2023. Resident had nasal cannula in her nose. In an interview on 02/12/2023 at 11:45 AM in Resident #18's room LVN D stated her humidifier was empty. She stated the date on the humidifier and the tubing was 01/05/2023 and this would be the last time the humidifier and tubing were changed. She also stated it was expected for the nurse to write the date on the humidifier and tubing whenever they were changed. She stated the last time the humidifier and tubing were changed on Resident #18 was 01/05/2023 according to the last date documented. She also stated the Resident's nose could become dry and irritated. She stated without changing the resident's tubing there was a possibility bacteria could be in the tubing. She stated it was very important to change the tubing and humidifier every week to prevent any discomfort for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 15 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 She stated there is a full humidifier bottle on her bedside table without a date on it. She stated she did not why it was not changed. She stated she worked weekends, but it was anyone's responsibility to inform nursing when the humidifier was empty. She stated no one in nursing had notified her that the humidifier needed to be changed. She stated it was standard for the humidifier and tubing to be changed every Wednesday and usually the night nurse changed the humidifier. She stated this was neglected by the nursing staff not to check and change the humidifier. She stated the nurses will usually document it in the nurses notes when the humidifier/ tubing was changed. She stated she was assigned to this resident but she did not recall last time she saw Resident #18. In an interview on 02/13/2023 at 2:30 PM Nurse E stated Resident #18 humidifier and tubing was to be changed once a week on Wednesdays. She stated the night nurse will change the humidifier and tubing on residents with oxygen. She stated she was not aware of the date when Resident #18's humidifier and tubing was changed. She stated the nurse will usually document it in the nurses' notes. She reviewed the nurses notes and electronic medical records. There was no indication of when the last time the humidifier or tubing was changed. In an interview on 02/14/2023 at 9:20 AM the DON stated all nurses were to date the humidifiers when the nurses changed the empty to a new humidifier and tubing on all resident's oxygen tanks. She stated whatever date is on the humidifier is the date we assume it was last changed. She stated if the date was 01/05/2023 and there was no other date on Resident #18's humidifier this was the date we assume it was last changed. She stated there was a full humidifier bottle on the bedside table not dated. She stated the humidifiers and tubing was changed once a week on Wednesdays or as needed. She stated it was the nurse's responsibility to ensure the humidifiers and tubing was changed. She stated if any staff observed the humidifier was empty, they were expected to notify the nurse. There were no other questions answered during this interview concerning the oxygen tank/ humidifier or tubing. In an interview on 02/14/2023 at 11:00 AM the DON and Nurse Consultant agreed that oxygen tubing should be changed weekly. The DON stated that the oxygen humidification should be used to prevent drying out the nasal passages and for the resident's comfort. The nurse consultant stated the facility did not have a policy on oxygen or standard practice of nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 16 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and preparation for one of one kitchen. A) The facility failed to defrost one freezer in the dry storage room to prevent ice covering containers of food and the inside of the freezer. B) The facility failed to properly store and label food in the facility's open front refrigerator, open front freezer, open top freezer, food prep table and the dry storage room. C) The facility failed to ensure Dietary [NAME] B properly sanitized hands between tasks. D) The facility failed to ensure Dietary Aide C wore a beard net when near the food steam table. These failures could place the residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: A) Observation of the kitchen equipment on 2/12/2023 at between 8:55 AM- 9:35 AM revealed a deep freezer opened from the top located in the dry storage room had approximately 12 inches of hard ice covering inside the freezer including all four sides, bottom of the freezer and outside of the freezer where the top of the freezer closes. There were four containers with approximately 6-8 inches of ice covering the unknown food. In an interview on 2/12/2023 at 9:05 AM the Dietary Manager A stated it was the Maintenance Supervisor responsibility to defrost the freezer. She stated she did not fill out any work order for maintenance. She stated there is a computer system on the wall in certain areas in the facility that is used only for maintenance work orders. She stated she did know how to use the maintenance computer system. She stated she did not use the maintenance computer system or verbally inform the Maintenance Supervisor concerning the freezer needed to be defrosted. She stated she did notice the freezer had too much ice in it last week and she forgot to fill out work order. She stated if the freezer was not defrosted there was a possibility ice would be in the packages of food and it could affect the freezer and she believed the freezer may stop working and all the food would spoil. In an interview on 2/14/2023 at 10:30 AM the Maintenance Supervisor stated he was not informed verbally of the freezer in the kitchen needed to be defrosted. He stated he could review the maintenance work orders. He stated if you want to review the work orders in the computer system, we can review them. He stated there was not any work orders to defrost the freezer in the computer system. Observation on 2/14/2023 at 10:35 AM revealed there were not any work orders in the maintenance computer system for the freezer to be defrosted. B) Observation of the food prep table, refrigerator, freezers, and dry storage area on 2/12/2023 between 8:55 AM and 9:35 AM revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 17 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 1. Food Prep Table: Level of Harm - Minimal harm or potential for actual harm - a flat tray of approximately 10 pureed fruit in small bowls with lids on top of each bowl sitting on the bottom shelf without a label. Residents Affected - Many - tray of approximately 17 regular texture fruit in small bowls with lids on top of each bowl sitting on the bottom shelf without a label. 2. Open Front Refrigerator: -left over pineapple in a partially opened clear plastic bag not in the original package without a label. -one partially opened clear plastic bag with left over carrots not in the original package without a label. - one large bag of celery not in the original package had a brown color on the edges to the middle of the celery without a label. -one clear plastic bag of left-over ham not in the original package without a label. - five small packages of sliced ham in a large clear plastic bag not in the original package without a label. - one tray of approximately 25 cups of variety of juices with lids on the cups without a label. - one tray of approximately 15 cups of tea with lids on the cups without a label. 3. Open top freezer located in the dry storage area of the kitchen: - one clear plastic of left-over hot dog buns covered with ice particles not in the original package without a label. - one angel food cake not in the original package without a label - one clear plastic bag of left-over cookies not in the original package without a label. - one large clear plastic bag of french fries not in the original package had approximately ¼ of ice particles covering the french fries without a label. 4. Dry Storage Room in the Kitchen: - two large blue crates of approximately 15-20 bowls of cereal on each crate without a label. - one bowl of cereal dated 2/5/2023. In an interview on 02/12/2023 at 9:20 AM the Dietary Manager A stated all food in the refrigerator, freezer and dry storage room was expected to be labeled and dated. She stated a resident had potential of becoming ill if they ate left over food that had been placed anywhere in the kitchen over two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 18 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many or three days. Any staff that places food in the freezer, refrigerator and/ or dry storage area was responsible to label and date the food. C) Observation on 02/13/2023 at 10:35 AM revealed Dietary [NAME] B was wearing gloves. She was preparing to pureed beef stew. She picked up wet stained cloth and wiped the food prep area. She placed the wet cloth in the sink. She touched the right side of her shirt. She was not wearing an apron. She picked up the lid of the pureed blender and placed beef stew in the blender. When she was placing the beef stew in the blender the ring finger on her right hand touched the beef stew. She began to puree the beef stew. When she stopped, she was reminded by the Dietary Manager A to change her gloves. Dietary [NAME] A changed removed her gloves and did not wash or sanitize her hands. When she picked up a new pair of gloves, she touched the fourchettes (long strips made for the fingers). She proceeded to place gloves on both hands. She continued with the task of making observation of the consistency of the pureed beef. She placed the lid of the pureed blender in the sink and there was white substance in the sing sink and on the right side of the sink. Her gloves touched a white substance located on the left side of the sink. She poured water into the pureed blender and picked up the lid from the sink. Dietary [NAME] A's forefinger, middle finger and ring finger touched the white substance on the right side of the sink. She placed more beef in the pureed blender and the forefinger on the right hand touched the beef. She moved to another area of the kitchen and reached for a large mixing spoon hanging on a column. When she reached for the large mixing spoon her thumb, forefinger and the side of her right hand touched the column. She walked to the prep area and continued to prepare the pureed beef without changing her gloves. In an interview on 2/13/2023 the Dietary [NAME] A stated at one time during preparation of the pureed beef, she did take her gloves off but did not wash her hands. She stated she did not know all the surfaces and items she touched while wearing her gloves when preparing the puree food. She stated she probably touched a lot of things that was contaminated she didn't know what she touched. She stated if her gloves were contaminated, she assumed the food would have some bacteria, but she did not know the effect the bacteria would have on the residents. She stated she was not a nurse. She also stated if she touched the column, she did not believe it had been disinfected. She stated the sink was probably cleaned last night. She stated she did prepare food without changing her gloves after she probably touched a lot of things that was not disinfected. She stated when she did change her gloves, she did not wash her hands and she did pick up the new gloves on the outside of the gloves where her fingers would be placed into the gloves. She stated she probably did contaminate the new gloves when she did not pick them up correctly. She stated she was not to touch the outside of the gloves. She stated she had been in serviced on washing hands and changing gloves when preparing food. In an interview on 2/14/2023 at 11:34 AM the Dietary Manager A stated all dietary staff was expected to wash hands and put on new gloves when they enter the kitchen. She stated when picking up new gloves it was expected not to touch outside of the gloves. She stated she did expect staff to change their gloves and wash their hands in between tasks or if they touched anything that may be considered contaminated. She stated she had in serviced all dietary staff on hand hygiene. She stated Dietary [NAME] A was expected to change her gloves and wash her hands if she touched anything when she prepared the beef stew puree. She stated a resident could become ill with stomach issues if staff touched the food wearing contaminated gloves. She stated she was not a nurse and was not going to speculate if a resident would require any type of treatment for stomach issues. Record review of hand hygiene in-service from dietary manager was requested on 02/14/2023 and was not provided at time of exit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 19 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many D) Observation on 02/13/2023 at 10:19 AM revealed Dietary Aide C was standing by the food prep table with his beard net under his chin and was not on his face properly. Dietary Aide C came to the door and washed his hands, and his beard was approximately 6-8 inches long and was not covered with a beard net. In an interview on 02/13/2023 at 10:22 AM Dietary Aide C stated he had been working in the kitchen a long time and he knew the rules of wearing a beard net. He stated he had one on and if must have fell off his beard. He stated he had been in serviced on wearing hair nets and beard nets. He stated there was a possibility hair could fall on anything. In an interview on 02/13/2023 at 10:55 AM Dietary Manager A stated any male staff in the kitchen was expected to wear a beard guard. She stated hair can fall from their beard into the food or on a resident's plate, in their cup or anywhere food was being prepped. She stated hair was not sanitary and possibly have bacteria on the hair. If resident ate someone's hair, there was a possibility a resident could become ill. She stated she was not a nurse and did not know the extent of illness. In an interview on 02/14/2023 at 10:39 AM the Administrator stated the dietary staff was expected to change their gloves between tasks and whenever touch any non-sanitized surfaces including clothes. When dietary staff removes their gloves, they are expected to wash their hands prior to replacing with new gloves. He stated when picking up new gloves the staff was expected to pick up the gloves from the inside and not touch outside of the gloves. If the outside of the gloves were touched, they would be considered contaminated. The males in the kitchen with a beard was expected to wear a beard guard. He stated there was a potential of hair falling from a man's beard onto the food, food prep table, plates, or cups. He stated by not following proper kitchen sanitation protocol there was a potential a resident could become sick with some type of stomach issues and possibly need medical attention. He stated it was a possibility a resident may need to be transferred to the emergency room for evaluation. He also stated the freezer needed to be defrosted. He stated the ice covering the containers of food was expected to be thrown in garbage. He stated the food would not be suitable to be eaten by the residents. He stated all food and drinks was to be labeled and dated especially left-over food. He stated with left-over food if there was not a date on the package no one would know when it was placed in the refrigerator and if it is over 48 hours it should be thrown in garbage. He stated he did go in the kitchen at random times and made observations. Review of Employee Sanitation Policy dated 2018 revealed the nutrition and foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of Refrigerators, Coolers and Freezers Policy dated 2018 revealed the following: The facility will maintain refrigerators Remove all items from the freezer and transfer to another freezer Dispose of all outdated food and discard all leftover items greater than 72 hours old. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 20 of 21 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 Turn freezer off 30-60 minutes prior to cleaning. - Residents Affected - Many Ensure drain is free so that water can flow freely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 21 of 21