Inspection·April 25, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm failure, weakness, adult failure to thrive, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), and age-related debility. Record review of Resident #247's Quarterly MDS assessment dated [DATE] revealed Resident #247 had a BIMS score of 14 indicating intact cognitive response. Residents Affected - Some Observation of hall 100 on 04/22/2025 at 11:57 am revealed that CNA B did not knock on Resident #70's door before entering the room. Observation of hall 100 on 04/22/2025 at 11:58 am revealed CNA B did not knock on Resident #85's door before entering the room. Observation of hall 100 on 04/22/2025 at 12:fpm revealed CNA B did not knock on Resident #247's door before going into the room. Observation on 100 hall on 04/23/2025 at 08:46 am revealed that LVN A did not knock on Resident #85's door before entering the room. An interview with Resident #70 on 04/23/2025 at 9:06 a.m., revealed that he did not want to talk to the surveyor. Resident #70 just looked at surveyor. An interview with Resident #85 on 04/23/2025 at 1:2 revealed that she was good and was just watching television. She would not answer questions about staff knocking. An interview with Resident #85's FM on 04/23/2025 at 1:45 p.m., revealed that staff knock at times and there were times that the staff do not knock. He said that he did not care if staff knocked because the door made a lot of noise, and he could hear the staff coming in. He said that staff not knocking did not upset him. During an attempted interview with Resident #247 on 04/23/2025 at 1:46 p.m., she said that staff never knock before going into her room. She said that it would make her happy if anyone who came into her room would knock first. She said that she did not get upset when staff did not knock. During an interview with LVN N on 04/23/2025 at 1:20 p.m., she said she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering, introduce themselves and tell the resident what they were going to do. She said that all staff were required to knock before entering the resident's room. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel like staff are intruding on their privacy. She said that the charge nurse or management monitor to ensure staff were knocking on the residents' doors. She said that the charge nurse or management monitored by observations. She said she realized she did not knock once she entered the room. She said she normally did knock but got distracted by the aides. During an interview with CNA B on 04/24/2025 at 11:26 am revealed that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering. She said that all staff were required to knock before entering the resident's room. She said that knocking was for the resident's privacy and dignity. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel like they do not have any privacy or respect. She said that the charge nurse monitor to ensure staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 2 of 28 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 04/25/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some knocking on the residents' doors. She said that the charge nurse monitored by observations. She said she was not sure why she did not knock on the residents doors before entering. An interview with the DON on 04/24/2025 at 11:30 a.m., revealed she and staff had been trained on resident rights. She said the policy was that staff were to knock on the door and that she was not sure if there was a policy. She said that staff were to knock except if it was an emergency such as the resident on the floor. She said it was important for staff to knock because it was the resident's right. She also said that if staff did not knock on the door, it might bother some residents but others it may not bother it would depend on the resident. She said that all management was responsible for monitoring to ensure staff were knocking. She said that management monitored it by doing observations. She said some of the staff were students and are still learning but for the ones who were not students, she said she did not know why they did not knock. An interview with the ADM on 04/24/2025 at 11:35 a.m., revealed that he and staff had been trained on resident rights. He said the policy was to knock on the door, pause wait for a response and then enter. He said that it was important for staff to knock on the residents' door for their privacy. He said the resident may feel like their privacy is being invaded, could hurt their dignity and cause the resident to feel disrespected. He said the only time staff did not need to knock on the resident's door was in the event of an emergency. He said that the charge nurse was to monitor to ensure that staff were knocking on the door. He said the charge nurses monitored knocking by observation of the halls. He said he did not know why staff were not knocking on residents' doors before entering . Record review of Promoting/Maintaining Resident Dignity Policy dated 1/13/2023 revealed it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity. Staff were to maintain resident privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 3 of 28 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 04/25/2025 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 record review and interviews, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for one (Resident #84) of 10 residents reviewed for care plans, in that: 1. The facility failed to ensure Resident #84's comprehensive care plan included a smoking plan. This failure could place the residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #84 Face sheet, dated 4/24/2025, reflected he was a [AGE] year-old man, who was admitted to facility on 12/30/24 with diagnoses of centrilobular emphysema (lung disease with damage to the air sacs), respiratory failure, obstructive pulmonary disease (chronic progressive lung disease), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), unsteadiness on feet, cognitive communication deficit (problems with communication), and muscle wasting and atrophy. Record review of Resident #84 Quarterly MDS dated [DATE] , indicated he had a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. Records review of Resident #84's comprehensive care plan dated 3/25/2025, reflected the resident's diagnoses with a focus on interventions that were actively being completed to support residents' health. Smoking was not reflected on care plan. In an observation and interview with Resident #84 on 4/22/2025 at 10:10 AM, resident was observed lying in his bed with oxygen. Resident stated that due to him being on antibiotics changed his smoking schedule. He stated he goes after the other residents, and when he goes out to smoke, he smokes alone. Resident stated if the state surveyors observed him by himself, the reason was due to him being on the antibiotics for his blood issues. In an observation and interview with Resident #84 on 4/23/2025 at 9:13 AM. Resident was sitting up in a chair, he stated he had just come from smoking. Resident was observed to be clean and neat in appearance . Records review revealed a smoking safety screen for Resident #84 was completed on 1/6/2025. In an interview on 4/24/2025 at 1:44 PM, Social Worker (SW) stated she has worked at the facility for four years. SW stated she has been trained on the smoking policy. SW was asked to explain the smoking policy. She stated all residents must be supervised unless they sign themselves out to smoke away from the facility property. SW was asked if smoking should be included on a care plan for a resident that smokes, SW stated yes, it should be on the care plan. SW was asked, what could be a potential outcome if smoking was not on the care plan. SW stated there could be a possible accident. SW was asked had Resident #84 signed himself out to smoke, SW stated he had in the past, but she did not know of anytime recently. SW stated she was not aware of Resident #84 smoking alone. SW stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 4 of 28 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 04/25/2025 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 Resident #84 was not supposed to smoke unsupervised. SW was asked why smoking was not included on the care plan for resident 84, SW stated it should be on the care plan. SW was told that smoking was not reflected on resident 84 care plan. In an interview on 4/24/2025 at 3:30 PM, Director of Nursing (DON ) stated, she was aware of the facility's smoke policy. DON stated residents have smoke times assigned and they must be supervised while smoking. DON was asked who was responsible for developing the care plan, DON stated the nursing team. DON was asked should smoking be included on a resident's care plan if they were a smoker, DON stated yes. DON was asked what potential outcomes could be when smoking is not reflected in the care plan, DON stated it can lead to opportunities for accidents. She stated that she was not aware of him smoking alone. Record review on 4/24/2025 of facility's Comprehensive Care Planning Policy dated 10/24/22 reflected the following: a) Care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B )resident's goals for admission, desired outcomes, and preferences for future discharge. b) Resident specific interventions that reflect the resident's needs and preference and align with the resident's cultural identity, as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 5 of 28 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 04/25/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 of 8 Residents (Resident # 22, Resident # 50, and Resident # 74) reviewed for ADLs. Residents Affected - Some The facility failed to ensure Resident #22, Resident #50, and Resident #74 nails were trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Record review of Resident #22's face sheet, dated 04/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behaviors ( person presented signs of loss of memory, language, problem-solving and other thinking abilities without behaviors), type 2 diabetes mellitus with diabetic neuropathy, unspecified ( a chronic disease characterized by high blood sugar levels, primarily due to the body's inability to effectively use or produce enough insulin- neuropathy causes pain, numbness, and tingling in different parts of the body), and multiple sclerosis (progressive disease involving damage to the nerve cells in the brain and spinal cord, whose symptoms may include numbness, impaired speech and of muscular coordination, blurred vision , and severe fatigue). Record review of Resident #22's Quarterly MDS Assessment, dated 04/09/2025, reflected Resident #22 had a BIMS score of 4 indicating her cognitive status was severely impaired. Resident #22 was totally dependent on staff for personal hygiene, showers, and oral hygiene. She required substantial /maximal assistance (helper does more than half the effort) with upper and lower dressing, and toileting hygiene. Review of Resident #22's Comprehensive Care Plan, completed on 04/04/2025 , reflected Resident #22 had an ADL self-care performance deficit related to decreased mobility, contractures, and chronic pain. Interventions: Resident #22 required extensive assistance by 1-2 staff with personal hygiene. Observation and interview on 04/22/2025 at 9:45 AM revealed Resident #22 was in her room lying in bed. Her nails on her right hand were not smooth around the edges and had a blackish/brownish substance underneath her middle, ring, and fore fingernails on her right hand. Resident #22 also had a blackish/brownish substance on the tip of her middle and ring finger on her right hand. She was not interviewable. Record review of Resident #50's face sheet, dated 04/23/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mild cognitive impairment of uncertain or unknown etiology ( a condition where an individual experiences memory or thinking problems that are noticeable but not severe enough to interfere with their daily activities, and the specific cause of these problems was unclear or has not been determined, altered mental status, unspecified ( confusion, disoriented and change in alertness, but without a clear diagnosis), vitamin D deficiency ( causes issues with bones and muscles, can lead to brittle bones, muscle weakness, and pain. Can result from lack of sunlight exposure or insufficient dietary intake), and anxiety disorder (excessive fear, worry that is not warranted to the situation). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 6 of 28 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 04/25/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of Resident #50's Quarterly MDS assessment dated , 03/31/2025, reflected Resident #50 had a BIMS score of 15, which indicated her cognition was intact. Resident #50 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or as needed) with personal hygiene, upper and lower body dressing, showers, and toileting. Residents Affected - Some Review of Resident #50's Comprehensive Care Plan, completion date of 04/21/2025, reflected Resident #50 had an ADL self-care performance deficit related to decreased mobility and poor strength. Interventions: Bathing/Showering: Check nail length and trim, clean on bath day and as needed. Report any changes to the nurse. Resident #50 required one staff assistance to provide shower and toileting. Resident #50 was total dependent on staff for personal hygiene. Observation and interview on 04/22/25 at 09:58 AM revealed Resident #50 was lying in bed in her room. Her nails on her right and left hands were not smooth around the edges and there was a blackish/brownish substance underneath her middle and fore fingernails on her right hand. She stated she asked someone over the weekend to file and clean her nails and the person stated they would sometime during the week. Resident #50 stated she did not recall the staff's name. She stated she believed the staff worked in nursing but did not recall if the staff was a CNA or a Nurse. Resident #50 stated she did not recall seeing a name badge on the staff's clothes. Review of Resident #74's face sheet, dated 04/23/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #74 had a diagnosis which included type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma ( severe complication characterized by extremely high blood sugar, severe dehydration, and altered consciousness- a temporary change from a person's normal mental state), vascular dementia, mild, with anxiety ( primarily caused by problems with blood vessels in the brain, due to stroke or mini-strokes- anxiety is a feeling of worry , nervousness, or unease, typically a current event or something with an uncertain outcome), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side ( and age -related physical debility ( can include muscle weakness- decrease strength or ability to perform task, fatigue, low physical activity). Review of Resident #74's Quarterly MDS Assessment, dated 02/13/2025, reflected Resident #74 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #74 required supervision or touching assistance (helper provides verbal cues and/or touching/ steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or as needed) with personal hygiene, showers, and toileting hygiene. She required setup or clean-up assistance (helper sets up or cleans up and resident completes the activity) with eating, oral hygiene, upper and lower body dressing, and putting on and talking off footwear. Review of Resident #74's Comprehensive Care Plans with a completion date of 03/03/2025 reflected Resident #74 had an ADL self-care performance deficit related to hemiplegia (a condition characterized by paralysis- the loss of ability to move- on one side of the body) Intervention: Resident #74 required extensive assistance by one staff with bathing or showering. She required limited assistance by one staff for personal hygiene and oral hygiene. Observation and interview on 04/22/2025 at 10:58 AM revealed Resident #74 was in her room lying in bed, on her right hand underneath her middle and ring fingernails was blackish/brownish substance. Resident #74 had rough edges around her fingernails on her right hand and had blackish/brownish substance underneath her middle and fore fingernails on her left hand. Resident #74 stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 7 of 28 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 04/25/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some like her nails to be dirty. She stated she did not remember if she asked someone to help her with her nails. Resident #74 stated her nails had been dirty and rough for the past 4 or 5 days. In an interview on 04/24/2025 at 9:35 AM, CNA I stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA I state the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA I stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given nail care to Resident #22, Resident #74, and Resident #50 and they did not refuse nail care. She stated if any resident refused nail care, she reported it to the nurse and the nurse would document the refusal in nurses' notes. In an interview on 04/24/2024 at 10:25 AM, LVN B stated the nurses were responsible for filing and trimming all residents' nails and the CNAs was responsible to clean all residents' nails except the residents with diagnosis of diabetes. She stated nail care on residents was completed weekly by the nurse. She stated this usually occurred on Sundays. LVN B stated CNAs were to clean underneath residents' nails as needed. She stated it depended on what type of bacteria was underneath the residents' nails if a resident became ill such as stomach issues. LVN B stated she was not a physician and was unable to answer what type of illness a resident may receive if the resident swallowed some type of bacteria. LVN B stated she had trimmed and cut residents' nails. She stated she was not aware of Resident #43 or Resident #59 refusing nail care. She stated the nurses documented in nurses' notes anytime a Resident refused any type of care including nail care. LVN B stated if a resident's nails were not trimmed properly and were jagged, there was a possibility the resident may scratch themselves, staff or other residents and cause a skin tear. She stated the nurse supervisor was responsible for monitoring the CNAs and nail care. In an interview on 04/24/2025 at 10:45 AM, the Director of Nurses stated she expected the nurse on duty to do all nail care on a resident. She stated the nurse or CNA can clean resident's nails. The Director of Nurses stated if a resident nails was not smooth around the edges of the nails, there was a potential the resident may scratch themselves or another resident and cause a skin tear. She stated also the resident may scratch their eye and may cause issues such as a tear on the eyeball. She stated the CNAs were expected to check resident's nails on shower days and report to the nurse supervisor if a resident nails needed to be trimmed, filed or any issues the CNA observed with the Residents fingernails. She stated if a resident had a blackish/brownish substance on tip of their finger or underneath their nails it was a possibility a resident may ingest the blackish/brownish substance and become ill such as vomiting and/or diarrhea. She stated if a resident refused nail care or any type of care the nurse was to document the refusal in the nurses' notes. In an interview on 04/24/2025 at 10:55 AM, CNA H stated the CNAs were responsible for cleaning the resident's nails and the nurses was responsible for cutting and filing all residents' nails. CNA H stated residents' nails were usually cleaned on their shower days or when needed. She stated if a resident's nails were dirty, nail care was expected to be completed immediately. CNA H stated if any staff observed resident's nails needed to bet cut or filed, the staff was to report the observation to the nurse supervisor. CNA H stated if a resident had nails not trimmed or was rough on top of the nail, there was a possibility a resident may scratch themselves and develop a skin tear. CNA H stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 8 of 28 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 04/25/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm stomach issues such as vomiting and being nauseated. CNA H stated she had been in-serviced on cleaning, filing, and trimming residents' nails. CNA H stated she did not remember the date of the in-service. CNA H stated she was not aware of Resident #50, Resident #74, or Resident #22 refuse nail care. CNA, H stated she worked at least 1-2 times a week on the halls where Resident # 22, Resident # 50, and Resident # 74 resided. Residents Affected - Some In an interview on 04/24/2025 at 11:18 AM, ADON stated the nurses completed all nail care on residents except cleaning resident's nails. She stated the Nurses were responsible to complete nail care such as trimming, filing, and cleaning once a week or as needed. ADON stated if staff observed a resident's nails needed to be trimmed or filed, the staff was to report it to the nurse supervisor. She stated the nurse or CNA can clean resident's nails but ultimately it was the CNAs responsibility during showers and/or as needed. ADON stated if a CNA noticed any concerns of a resident's nails, the CNA was expected to report any concerns to the nurse. She stated the nurse was expected to assess the residents nail, document concern in the nurses note and call the physician and the family, if needed. ADON stated if a resident had blackish substance underneath their nails there was a possibility a resident may become ill such as nausea or diarrhea depending on the type of bacteria. ADON stated if a resident had rough edges around their nails, it was a possibility the resident may scratch themselves and develop an infection or a skin tear. She stated she was not aware of Resident #50 or Resident #74 or Resident #22 refusing nail care. ADON stated any refusal of nail care would be documented in the nurses' notes. She stated the nurse supervisors were responsible for monitoring the CNAs and nail care. The ADON stated the ADON and DON was responsible to monitor the nurse supervisors . Review of the facility's Activities of Daily Living (ADLs) Policy, dated 05/26/2023, reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 9 of 28 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 04/25/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and once developed, failed to ensure necessary treatment and services to promote healing for two (Resident #249 and Resident #40) of five residents reviewed for pressure ulcers. Residents Affected - Some A) The facility failed to ensure Resident #249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2024 through 04/20/2025. Resident #249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. B) The facility failed to ensure RN A notified Resident #249's physician on 04/20/25 at 4:20 PM when she observed a brown spot on Resident #249's sacral area. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/24/2025. The IJ template was provided to the facility on [DATE] at 2:28 PM. While the IJ was removed on 04/25/2025, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Non immediate jeopardy B) The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3 sacral pressure ulcer that did not cross contaminate the pressure ulcer. This failure could place residents at risk for worsening of pressure ulcers leading to discomfort, pain, and potential infections. Finding Include: A) Review of Resident #249's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses fracture of unspecified part of left femur neck (hip fracture), cognitive communication deficit, and muscle wasting and atrophy. Review of Resident #249's 5-Day MDS dated [DATE] reflected a BIMS of 13 indicating she was cognitively intake. Resident #249 was assessed to require supervision or touching assistance with toileting and partial to moderate assistance with transfers. Resident #249 was assessed to be occasionally incontinent of urine and continent of bowel. Review of Resident #249's comprehensive care plan reflected a problem dated 04/08/2025 which reflected The resident has potential impairment to skin integrity related to incontinence. Interventions included Monitor/document location, size, and treatment of skin injury. Report abnormalities . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 10 of 28 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 04/25/2025 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 0686 Review of Resident #249's admission nursing assessment dated [DATE] reflected she had no skin issues. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #249 PCC skin & wound assessment dated [DATE] reflected no skin concerns noted to peri or coccyx area. Residents Affected - Some Review of Resident #249's weekly skin assessments reflected no skin assessment was conducted from 04/08/2025 until 04/20/2025. Review of Resident #249's PCC skin & wound assessment dated [DATE] conducted by RN A reflected Resident #249 had no new wounds. In an interview on 04/24/2025 at 9:10 am RN A stated Resident #249 had a fall around 4:20 pm on 04/20/2025 in her bathroom. RN A stated Resident #249 went to the bathroom on her own and fell. RN A stated she conducted an assessment after the fall and did not see any injuries. She stated at that time she did not look at her sacral area closely and stated she did not smell anything like necrosis. RN A stated that around 9:45 pm a CNA came to her and reported the resident had a brown spot on her sacral area. She stated she left a note for the next shift to assess the area. Review of Resident #249's nursing progress notes reflected an entry dated 04/20/2025 at 9:50 pm CNA notified this nurse about resident having a new wound. Went to assess, noted small wound to resident's bottom with eschar area to wound bed. Skilled wound care nurse to be notified. Progress note signed by RN A. In an interview on 04/24/2025 at 3:05 pm CNA O stated she worked the evening of 04/20/2025 (2pm-10pm shift) and took care of Resident #249. She stated she helped Resident #249 into the bathroom and noticed red color spot on her bottom but denied seeing a wound or skin tear. She stated that she notified the nurse right away and the nurse whose name she does not remember came right away. In an interview on 04/24/2025 at 9:19 am the Treatment nurse stated she saw Resident #249 for wound care on 04/18/2025. She stated she did not do a full skin assessment on that day that she just looked at Resident #249's left hip incision and did not see anything else. She stated Resident #249 was on the commode when she performed the assessment and that she looked at her buttocks but did not look in depth at her sacral area. She stated she did not do treatments on residents with only surgical wounds that the floor nurses did those wound assessments. The Treatment nurse stated on 04/21/2025 that she did not assess Resident #249's skin. The Treatment nurse stated she had no idea how Resident #249's unstageable sacral pressure injury developed. In an interview on 04/24/2025 at 9:45 am the ADON stated she was working the floor on 04/21/2025. She stated on 04/21/2025 around 3:00 pm the CNAs went to lay Resident #249 down in bed and she was complaining of left hip pain. She stated they then turned Resident #249 over on her side they found a large dark area on her sacral area that had odor and covered her entire sacral area. The ADON stated she informed Resident #249's PA. Review of Resident #249's nursing progress note dated 04/21/2025 at 3:24 pm reflected Sent to (hospital) for wound care consult/patient with new sacral wound plus odorous and needs debridement . note signed by the ADON. In an interview on 04/24/2025 at 10:00 am Resident #249's PA stated she received a call from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 11 of 28 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 04/25/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some facility on 04/21/2025 that Resident #249 had a new area to her sacrum. She stated she assessed the area and found an unstageable pressure ulcer to her sacrum that was malodorous. She stated at first, she thought that it might be an abscess, but she had not gotten the hospital paperwork yet to verify that. When asked if Resident #249 could have developed the pressure ulcer in one day since the skin assessment on 04/20/2025 reflected she did not have any skin conditions Resident #249's PA stated a pressure ulcer can develop in that time frame but not necrosis that generally takes about a week. She stated Resident #249 was [AGE] years old but can get up in a wheelchair and move around. Resident #249's PA stated she saw Resident #249 on 04/17/2025 and she complained of hip pain but no other pain. She stated she did not assess her skin at that time. When asked if not performing skin checks could be a factor in the development of the pressure ulcer, she stated it could be a factor yes. She stated, I asked the nurses how we not saw this. Resident #249's PA stated Resident #249's pressure ulcer could not have developed over night, that it was very questionable given the necrosis. Review of Resident #249's PA note dated 04/21/2025 reflected new malodorous decubitus wound .due to concern for infection, I recommend pt (patient) to go to hospital to have wound consult asap (as soon as possible) . Review of Resident #249's hospital records dated 04/21/2025 reflected This is a [AGE] year-old woman with a past medical history of hypertension (high blood pressure), hyperlipemia (high levels of fat in the blood) and hypothyroidism (decreased production of thyroid hormones) who presents from an inpatient rehab facility after having left hip surgery several weeks ago now developing sacral pain over the last week with a large sacral decubitus ulcer. The patient appears to have a central area of necrotic issue with surrounding cellulitis approximately 8 cm in diameter. She will require debridement routinely and antibiotic coverage with PT wound care for healing .8 cm in diameter necrotic decubitus ulcer with surrounding erythema .patient with possible sepsis Further review of Resident #249's hospital record reflected on 04/22/2025 she was diagnosed with sacral wound sepsis. Review of the operative report reflected preoperative diagnosis sacral pressure ulcer (unstageable) postoperative diagnosis sacral pressure ulcer (Stage IV) debridement down to and including sacral bone. Post debridement measurements 20cm x 15cm x 4cm wound vac application. With findings necrotic muscle extending to bone with copious purulence and malodorous smelling wound . Interview on 04/24/2025 at 10:55 am the DON stated when the facility was made aware of Resident #249's new pressure ulcer they sent her out to the hospital right away. She stated the facility started in-servicing staff and did a skin audit. She stated there were a lot of opportunities to see Resident #249's pressure ulcer that were missed. She stated if Resident #249's skin assessment had been done weekly it defiantly could have made a difference in the outcome if it had been caught earlier. In a follow-up interview on 04/24/2025 at 3:00 pm the DON stated that the facility regularly pulls up a list of residents' due weekly skin assessments, she stated every other day of so. She stated when they started looking into Resident #249, she found that her weekly skin assessment did not populate to alert the staff to do a skin assessment. The DON stated she did not know why the assessment did not populate. She stated the facility started training on how to complete a full and thorough skin assessment. She stated residents not being monitored and skin assessments being performed could contribute to residents having pressure ulcers not known by the facility. She stated she expected CNAs to tell nurses if a resident was not bathing and expected the staff nurses and aides to take every care opportunity to view the residents' skin for changes. In an interview on 04/24/2025 at 3:20 pm the Administrator stated he expected skin assessments to be done weekly and a thorough skin assessment be conducted. He stated if a thorough skin assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 12 of 28 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 04/25/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some had been conducted for Resident #249 the pressure sore would have been caught earlier. He stated if staff were charting on a skin assessment form, then a full and thorough skin assessment should be conducted. Review of the facility's undated policy Skin integrity management system reflected A head-to-toe body evaluation will be completed on every resident upon admission or readmission on the Initial Nursing Evaluation. Weekly thereafter the evaluations will be documented on the Weekly Skin Evaluation UDA. If skin is intact, no further action is required. If skin is compromised, proceed to the Weekly Wound Progress UDA. Identified skin areas will be documented on the Weekly Pressure or Non-Pressure UDA. Wound progress is to be documented each week with measurements and wound descriptions .Routine weekly checks will be completed on each resident; if skin is intact, it will be noted as such. If a new pressure injury is noted, a Weekly Pressure or Non-Pressure UDA will be started. Notification of Physician and Responsible Party will be documented in the Progress Notes. Assignments for skin evaluations will be scheduled. These assignments are to be monitored for completion . B) Review of Resident #40's face sheet dated 04/16/2025 revealed Resident #40 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), Dysphagia (difficulty swallowing), Parkinson's Disease with Dyskinesia (a progressive disorder that affects the nervous system), Neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), and unspecified Fracture of Sacrum (a broken bone in the lower back near the tailbone). Record review of Resident #40's MDS assessment, dated 04/16/2025, reflected Resident #40 was readmitted to the facility on [DATE] following a short-term hospital stay. MDS assessment had not been completed at the time of the survey. Record review of Resident #40's care plan reflected a focus area, dated 04/23/2025, reflected The resident has stage 3 pressure ulcer to sacrum date of development 04/21/2025 r/t skin frailty, immobility and incontinence. Goal included, resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target date: 06/28/2025. Observation on 04/23/2024 at 8:18 am revealed the Treatment Nurse in Resident #40's room to provide wound care. She removed the dressing covering the wound, then provided incontinent care to Resident #40. She wiped feces off the resident's perianal area with a moist perineal wipe and used the soiled wipe to wipe the skin around the open wound. She later used clean moistened gauze to wipe the skin surrounding the wound, before using the soiled gauze to wipe the open wound bed. Interview with Treatment Nurse on 4/24/25 at 09:20 AM stated that the proper technique for performing wound care is to wipe from the inner aspect of a wound and clean outward to prevent cross-contamination of a wound. Stated, that wasn't ideal at all when informed that she wiped around the open wound when cleaning feces off the resident's skin, and then later wiped the surrounding skin before cleaning the wound bed with the same moistened gauze during wound care to Resident #40. She stated that the resident could get an infection if the wound was contaminated with feces. Interview on 4/24/25 at 02:32 pm with DON stated that her expectations for wound care technique is that the wound bed be cleaned from the center of the wound bed outward. Stated that fecal contamination of the wound could lead to a wound infection and decline of the wound. Stated that hand hygiene should be done prior to medication administration per policy. Stated that the staff could cross (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 13 of 28 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 04/25/2025 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 0686 contaminate the resident if hand hygiene is not performed. Level of Harm - Immediate jeopardy to resident health or safety Interview on 4/24/25 at 03:31 pm with Administrator stated that his expectation is that incontinent care be performed prior to proceeding with wound care. Residents Affected - Some In a follow-up interview on 04/25/2025 at 09:40 am the Administrator stated that if there was contamination in a wound, there is a possibility that a resident may need further intervention such as antibiotics. Review of facility's policy on Infection Prevention and Control Program dated 05/13/2023, reflected All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy on Pressure Ulcer Prevention and Management dated 08/15/2022, reflected The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to .ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. The Administrator was notified on 04/24/2025 at 1:37 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 04/25/2025 at 1:15 pm. Letter of Credible Allegation For Removal of Immediate Jeopardy Attention Sir or Madam On 04/22/25 an annual survey was initiated at the facility. On 04/24/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy situation to resident health and safety. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusion set for in the verbal and written notice of immediate jeopardy and/ or any subsequent Statement of Deficiencies. The immediate jeopardy allegations are as follows.

F686 Quality of Care Pressure The facility failed to ensure Resident # 249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2025 through 04/20/2025. Resident # 249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 14 of 28 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 04/25/2025 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 0686 Resident #249 remains hospitalized . Level of Harm - Immediate jeopardy to resident health or safety Actions for Resident Involved Residents Affected - Some On 4/24/2025 the Treatment Nurse was re-educated on completing thorough skin assessments by the * Director of Nurses and suspended. Identification of Others * On 4-24-2025, the nursing facility conducted 100% head to toe assessment to ensure that residents with skin alterations were identified and documented. All skin assessments were documented on the PCC total body skin assessment form and saved in the resident's medical record. For any alterations in skin integrity, orders will be reviewed, and documentation reviewed to ensure license staff are following facility skin assessment and pressure ulcer prevention and management policy. * 3 residents were identified with newly developed rashes, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 resident identified with MASD to the sacrum, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 open blister was identified, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect the treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 15 of 28 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 04/25/2025 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 0686 Systemic Changes/ Education Level of Harm - Immediate jeopardy to resident health or safety On the Director of Nursing initiated education with 100% of licensed staff. Education was completed 4-24-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. Residents Affected - Some * Skin Assessment Policy * A full body, or head toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 16 of 28 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 04/25/2025 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 0686 * Level of Harm - Immediate jeopardy to resident health or safety The presence of a new pressure injury or skin alteration upon identification. Residents Affected - Some The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. * * Any complications (such as infection, development of a sinus tract, etc.) as needed. * Skin Integrity Management System * Notification of Changes Policy On 4/24/25 The Regional Clinical Specialist initiated the following education with 100% of licensed staff. Education will be completed 4-25-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents. * Skin Assessment Policy * A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. * The DON and/or designee will provide oversight of completion of skin assessments up-on admission/re(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 17 of 28 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 04/25/2025 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 0686 admission and weekly thereafter and will document on the findings on the facility clinical [NAME]-up form. Level of Harm - Immediate jeopardy to resident health or safety * the documentation of each assessment is noted in PCC by the nurse completing assessment. The Director of Residents Affected - Some Nurses/ designee will run the Total Body Skin Assessment from PCC each weekday, audit for missing assessments, and assign completion as appropriate. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: * The presence of a new pressure injury or skin alteration upon identification. * (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 18 of 28 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 04/25/2025 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 0686 The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. Level of Harm - Immediate jeopardy to resident health or safety * Residents Affected - Some * Any complications (such as infection, development of a sinus tract, etc.) as needed. The notification of the physician is noted in PCC and will be tracked for completion by the DON and/or designee through the review of the PCC 24 hrs. report. * Skin Integrity Management System. The documentation of this training is recorded on the facility's Inservice Training Report. * Notification of Changes Policy- The documentation of this training is recorded on the facility's Inservice Training Report. On 4-24-2025, the Regional Clinical Specialist re-educated the Director of nursing and ADONS on monitoring the skin integrity system to include completion of weekly skin assessment for each resident. Training recorded on the facility Inservice Training Report * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training content. Monitoring The Director of Nursing or designee will audit PCC total body assessment each weekday to ensure timely completion of skin assessments for each resident. o The PCC total body assessment audit will be documented on the facility's Clinical Stand-up Meeting form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 19 of 28 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 04/25/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The Director of Nursing and/or designee will ensure competency of the Licensed Nurses (Licensed Vocational Nurses and Registered Nurses) weekly x 4 by return demonstration of head-to-to-toe assessment and visual inspection of the resident's skin. o The verification of licenses nurse's competency will be documented on the facility Skin Assessment competency form. The Director of Nursing or designee will review the pressure ulcer log weekly following wound measurements to ensure that up-on identification of a new wound the physician was notified and that the wound assessments reflect the change in condition. o The review of the pressure ulcer log will be documented on the facility Clinical Stand-up Meeting form. o For any new admissions or resident requiring daily attention on the weekend, the on-call facility nurse manager will monitor for completion of assessment and ordered treatments. The Director of Nursing or designee will monitor compliance each weekday morning. The results of the findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed. o The compliance monitoring will be documented on the facility's monthly QAPI form. Skilled Wound Care Physician group will provide weekly review of residents with wounds. o Skilled Wound Care Physicians will provide weekly assessment and review of the residents with wounds by conducting weekly rounds. Rounds will be documented on the SWC provider Communication Log for Daily Rounds. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/ or designee reviews the documentation in PCC during the morning clinical meeting. The facility will evaluate the effectiveness of this plan during the Monthly Quality Assessment and Assurance Committee Meeting attended by at least the Administrator, Director of Nursing, Medical Director and at least three other staff members and the Infection Preventionist. The facility QAPI Committee reviews facility trends including Pressure Ulcer Reports and completion of weekly skin assessments. An Ad Hoc QAPI was conducted on 4-24-2025, by the Administrator, with the Medical Director, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 20 of 28 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 04/25/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Director of Nursing, and the Regional Clinical Specialist concerning pressure ulcers and to develop the above-mentioned plan of care. We respectfully submit this action plan for the removal of Immediate Jeopardy. The Survey Team monitored the POR on 04/24/2025 through 04/25/2025 as followed: Residents Affected - Some In an interview on 04/25/2025 at 1:23 pm LVN P (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the DON and the Nurse Consultant. The in-service was on wound and skin assessments and how to do assessments and notification of changes. We do weekly skin assessments on everyone in the building, on new admits, readmits and residents with change of condition. Know how to properly assess the resident. Know what to look for on a head-to-toe assessment. Know the 2 forms total body assessment do this on everyone whether they have wounds or do not have wounds. The 2nd form is what we do in iPad, and we do the wound assessment on it, and we take a picture of the wound we fill out the characteristics progress of the wound and it automatically does the measurements of the wound. Document this on a skin assessment form and it has the width length and depth for the nurse to document. The total body assessment- document skin color, temperature, moisture, condition and enter the number of wounds. I cannot recall everything on the skin assessment without looking at the form. The nurse documents the type of wound she stated LVN's could not stage a wound and would need someone else to stage such as RN or the Physician or Nurse Practitioner. If Resident has a burn put what type of degree of burn and would refer to RN or Physician for assistance if needed. Document if there was any slough if resident has staples how many does the resident have. The measurements of the wound how long the resident had the wound. Was the resident admitted with the wound. In an interview on 04/25/2025 1:48 pm LVN Q (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the Nurse Consultant and the DON did the in- service. Every time do a skin assessment do it weekly, any new admits, readmits, or change of condition. Inservice on notification of changes. I had to repeat what I learned during in-service to the DON. We have a list of who gets a skin assessment included people with wounds and without wounds every day. We must do head to toe assessment if there are some findings any bruises any skin tears pressure ulcer, we must make sure the pressure points are not red. She stated head to toe assessment was looking at the scalp, all areas of the ears, underneath both arms - arm pits, both arms, stomach area, if a female look under the breast and if a male would look under [NAME] the scrotum. I would open the buttocks area and look to determine if there was any wounds or area inside the buttocks look outside the buttocks, especially the sacral area. If have any fat rolls anywhere on the body look under the fat rolls. Would look at the thighs, both upper and lower leg extremity, look at ankles, heels, underneath the feet and in between toes. Would follow the skin assessment and document any findings of the skin assessment of the resident on the skin assessment. If find a pressure ulcer I will do skin assessment on IPAD we can take picture of the wound, I would look first photo how it looked and if needed to take another photo would take another photo. After the picture is taken on the IPAD it directs you what to do next. And you would click on options and the IPAD would measure the wound. You would point the iPad to the head of the resident and take picture and it would show you the measurements of where the wound was located. When you take a picture it gives option where it says where is the position where the head of the patient point the camera to the wound it tells where is the location of the wound and click on it and it gives you a diagram of the person it has option to rotate to get the actual site of the wound it will ask all characteristics of the wound such as is it draining, does it have an odor s/s of infection and gives the option it gives to measure but as an LVN cannot stage. I would call the doctor and get orders and tr[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 21 of 28 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 04/25/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 of 1 kitchen reviewed for food and nutrition services. Residents Affected - Some The facility failed to ensure Dietary [NAME] L followed the puree recipe for biscuits and added apple juice instead of water or stock to the bread puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings include: Observation on 04/23/2025 at 10:20 AM, revealed Dietary [NAME] L placed 6 biscuits into the puree blender. She did not measure apple juice and poured apple juice on top of the biscuits and began to puree the biscuits. The biscuit puree was very thin almost liquid form. Dietary [NAME] L continued to add the apple juice. There was a recipe for puree fish hanging on the top shelf for the Dietary [NAME] L could review when she pureed the fish. However, there was not a recipe for puree biscuits. Interview on 04/23/2025 at 10:30 AM, Dietary [NAME] L stated she always used apple juice when she purees bread. She stated she had puree bread so many times she did not need to review the recipe. Dietary [NAME] L stated the recipe was in a manual in the manager's office on a shelf toward the back of the kitchen. She stated she did not measure the apple juice and did not know how much apple juice was needed to puree biscuits. Dietary [NAME] L stated there were six residents on the puree diet. She stated she was recently in-service on how to puree food and she did have training on pureeing food. She did not recall the date. Review on 04/23/2025 at 10:35 AM, of the biscuit puree recipe reflected food thickener bulk use 1 tablespoon plus ¾ teaspoon for 5 servings. Water or stock use ½ cup plus 2 tablespoons. Prepare slurry (a mixture typically made from a thickening agent, such as flour or cornstarch, which is used to thicken food). Process until smooth using 1 oz of slurry per biscuit. Chill and hold at 41-degree Fahrenheit or below for service. Interview on 04/23/2025 at 10:50 AM, the Dietary Manager stated stock was the same as apple juice . She stated the Dietary [NAME] L did not prepare the puree biscuit correctly. She stated she was expected to follow the recipe and to measure the apple juice and Dietary [NAME] L did not do either one of these instructions. She stated she had in-service the staff few months ago on how to puree food and Dietary [NAME] L was in the in-service. Interview on 04/23/2025 at 11:50 AM, the Dietary Consultant stated all cooks were expected to follow all recipes including puree recipes. She stated the apple juice was not appropriate to use when pureeing biscuits or any type of bread. Dietary Consultant stated gravy would have been the better option to use when puree biscuits and use thickener if needed. She stated when pureeing any type of food, the cooks were expected to use the spoon test to place the puree food on back of the spoon and if it did not fall into the bowl, it was at the correct consistency. She stated Dietary [NAME] L will be re-educated on how to puree food correctly and will observe Dietary [NAME] L when she pureed food. She stated she was a new consultant to this facility and will ensure all dietary staff was re-educated on puree food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 22 of 28 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 04/25/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm In an interview on 04/24/2025 at 10:00 AM, the Administrator stated he expected the cooks to follow the recipe when preparing puree food or any type of food. He stated there was a possibility if the puree food was not the correct consistency, a resident may aspirate when eating the puree food. The Administrator stated the Dietary Manager was responsible to monitor the kitchen and the kitchen staff and he was responsible for monitoring the Dietary Manager. Residents Affected - Some Review on 04/24/2025 the facility in-service training, dated, 03/20/2025, reflected puree consistency in-service was given to all dietary staff including Dietary [NAME] L. Dietary Manager and Dietary Consultant gave the in-service. Requested a policy on preparing puree diets on 4/23/2025 at 10:50 AM, Dietary Manager stated they referred to the puree recipe for their policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 23 of 28 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 04/25/2025 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide K wore a beard guard when standing over clean dishes in the dishwashing room. 2. The facility failed to ensure Dietary [NAME] M used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 04/22/2025 at 9:10 AM, Dietary Aide K was not wearing a beard guard when standing in the dishwasher room over clean dishes. His beard growth was approximately 10 inches. Interview on 04/22/2025 at 9:15 AM, Dietary Aide K stated he was expected to wear a beard guard anytime he was in the kitchen area. He stated if hair fell onto plates and the hair transferred to residents' food there was a possibility a resident may become ill with some type of stomach issues (when asked what type of stomach issues he did not respond to the question). He stated germs were located on hair. Dietary Aide K stated he had been in-service on wearing beard guards. He stated it was in February 2025 or March 2025. He did not recall the exact date. 2. Observation on 4/22/2025 at 9:25 AM, Dietary [NAME] M was not wearing gloves. He touched the right side of his shirt with his middle finger, ring finger and fore finger on his right hand. Dietary [NAME] M touched the area of a large cooking spoon where the cook later used when stirring food for lunch without sanitizing his hands. He removed gloves from the glove box when his right middle, ring and fore fingers touched the Touchette's (area of the glove for the fingers), and he did not sanitize or wash his hands. Dietary [NAME] M continued to do food preparation with the gloves on his hands. Interview on 04/22/2025 at 9:30 AM, Dietary [NAME] M stated he did not wash or sanitize his hands when he touched inside the serving spoon and did use the serving spoon in the pots on the stove when placing potatoes in the pots. He stated he did not wash his hands prior to placing new gloves on both hands. Dietary [NAME] M stated he did touch his shirt. He stated his shirt was considered contaminated and if he touched anything contaminated, he was to wash his hands immediately. He stated there was a possibility germs from his shirt may cross contamination. Dietary [NAME] M stated germs may transfer to the food from his hands. He stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach problems such as vomiting. He stated he had been in-service on hand hygiene but did not remember the date of the in-service. Interview on 4/24/25 at 8:30 AM Dietary Manager stated hair nets or cap and beard guard on facial hair are required for all staff while in the kitchen. Dietary Manager stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. Dietary Manager stated it was her responsibility to ensure beard restraints were worn by the male staff in the kitchen. Dietary Manager did not answer why dietary aide did not properly wear a beard guard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 24 of 28 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 04/25/2025 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 - Some while in the kitchen even though he had facial hair. She stated all staff were to wash hands after touching anything. Interview on 04/24/25 at 12:30 PM the Administrator stated his expectation was that hair restraints were to be worn by all staff in the kitchen. The ADM stated if hair restraints are not worn there was a possibility a hair may fall into food. He stated there was a possibility if a resident ingested a hair the resident may become ill with some type of stomach issues. The Administrator stated he was not a nurse and did not know the extent of stomach illness getting into the food. The ADM stated all kitchen staff are responsible for wearing hair restraints and that ultimately the DM was responsible for ensuring hair restraints are worn by all staff in the kitchen. Record review of the Facility's Policy on Employee Sanitation, dated 05/10/2018 reflected: 1. Hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints or other effective hair restraints are worn to keep hair from contacting food and food-contact surfaces. 2. Hand washing: a. Immediately before engaging in food preparation including working with exposed food, clean equipment, utensils, and unwrapped, single-service and single-use articles. b. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 25 of 28 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 04/25/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #40 and Resident #1) of 18 residents reviewed for infection control practices. Residents Affected - Few 1. The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3 sacral pressure ulcer that did not cross contaminate the pressure ulcer. 2. The facility failed to ensure that MA C performed hand hygiene prior to medication administration for Resident #1. The failure related to wound care technique could place residents at risk for healthcare associated cross contamination leading to worsening of pressure ulcers discomfort, pain, and potential infections. The failure with hand hygiene prior to medication administration could place the residents at risk for healthcare associated cross contamination and possible infections related to the contamination of the environment and oral medications. Findings included: Review of Resident #40's face sheet dated 04/16/2025 revealed Resident #40 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), Dysphagia (difficulty swallowing), Parkinson's Disease with Dyskinesia (a progressive disorder that affects the nervous system), Neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), and unspecified Fracture of Sacrum (a broken bone in the lower back near the tailbone). Record review of Resident #40's MSD assessment, dated 04/16/2025, reflected Resident #40 was readmitted to the facility on [DATE] following a short-term hospital stay. MDS assessment had not been completed at the time of the survey. Record review of Resident #40's care plan reflected a focus area, dated 04/23/2025, reflected The resident has stage 3 pressure ulcer to sacrum date of development 4/21/25 r/t skin frailty, immobility and incontinence. Goal included, resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target date: 06/28/2025. Observation on 04/23/2024 at 8:18 AM revealed the Treatment Nurse in Resident #40's room to provide wound care. She removed the dressing covering the wound, then provided incontinent care to Resident #40. She wiped feces off the resident's perianal area with a moist perineal wipe and used the soiled wipe to wipe the skin around the open wound. She later used clean moistened gauze to wipe the skin surrounding the wound, before using the soiled gauze to wipe the open wound bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 26 of 28 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 04/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Treatment Nurse on 4/24/25 at 09:20 AM stated that the proper technique for performing wound care is to wipe from the inner aspect of a wound and clean outward to prevent cross-contamination of a wound. Stated, that wasn't ideal at all when informed that she wiped around the open wound when cleaning feces off the resident's skin, and then later wiped the surrounding skin before cleaning the wound bed with the same moistened gauze during wound care to Resident #40. She stated that the resident could get an infection if the wound was contaminated with feces. Interview on 4/24/25 at 02:32 PM with DON stated that her expectations for wound care technique is that the wound bed be cleaned from the center of the wound bed outward. Stated that fecal contamination of the wound could lead to a wound infection and decline of the wound. Stated that hand hygiene should be done prior to medication administration per policy. Stated that the staff could cross contaminate the resident if hand hygiene is not performed. Interview on 4/24/25 at 03:31 PM with Administrator stated that his expectation is that incontinent care be performed prior to proceeding with wound care. Stated his expectation was that hand hygiene should be performed prior to medication administration. Follow-up interview on 04/25/2025 at 09:40 AM with Administrator stated that if there was contamination in a wound, there is a possibility that a resident may need further intervention such as antibiotics. Stated that there is a possibility of cross contamination if staff did not wash or sanitize hands prior to administering medications to a resident. Stated that the resident has a potential to develop stomach issues such as nausea and vomiting, depending on the type of bacteria. Review of facility's policy on Infection Prevention and Control Program dated 05/13/2023, reflected All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy on Pressure Ulcer Prevention and Management dated 08/15/2022, reflected The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to:ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. Record review of Resident #1's face sheet, dated 04/23/2025, reflected Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with a diagnosis of Seizures, Vascular Dementia (dementia related to the blood vessels of the brain), Anxiety, and transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve withing 24 hours). Record review of Resident #1's MDS assessment, dated 02/20/2025, reflected Resident #1 had a BIMS score of 12, indicating moderate cognitive impairment. Record review of Resident #1's care plan reflected a focus area, dated 03/03/2025, The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia. Interventions indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness. Observation on 04/23/25 at 09:43 AM revealed MA C did not perform hand hygiene when entering the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 27 of 28 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 04/25/2025 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 0880 Resident's room prior to administering oral medications to Resident #1. Level of Harm - Minimal harm or potential for actual harm Interview with MA C on 4/24/2025 at 9:48 AM stated that she did not perform hand hygiene prior to administering medications to Resident #1. Stated that normally she would clean from the inner part of the wound to the outer surrounding skin. Stated that the resident could possibly get an infection if hand hygiene was not performed prior to medications. Residents Affected - Few Review of the facility's policy on Infection Control, dated 05/13/2023, reflected Hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's policy on Medication Administration, dated 10/01/19, reflected, Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 28 of 28