Inspection·May 29, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm was admitted to the facility on [DATE]. Resident #190's diagnoses included low back pain, need for assistance with personal care, unsteadiness on feet, weakness, reduced mobility, need for continuous supervision, dysarthria (speech sound disorder), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), hypertensive heart and chronic kidney disease (damage to heart and kidneys due to chronic high blood pressure), and insomnia (difficulty sleeping). Residents Affected - Some Record review of Resident #190's Quarterly MDS assessment dated [DATE] reflected Resident #190 had a BIMS score of 06 indicating severe cognitive impairment. Observation of one hundred hall on 05/27/2025 at 12:20pm reflected that CNA A walked in Resident #17's room without knocking. Observation of five hundred hall on 05/27/2025 at 10:01am reflected that Activity Assistant walked in Resident #52's room without knocking. Observation of six hundred hall on 05/27/2025 at 10:11am reflected that Activity Assistant walked in Resident #190's room without knocking. During an interview with Resident #52 on 05/28/2025 at 12:50pm revealed that staff do not always knock on the door. She said that she would like for them to knock all the time. She said she did not like to be surprised when staff just walked in. She said that she would get upset when staff pound on the door instead of knocking. During an interview with Resident #17 on 05/28/2025 at 2:31pm the resident just smiled and said she was good. She nodded her head when asked if she would like staff to knock all the time. When asked any other questions she would not nod or answer. During an interview with Resident #190 on 05/28/2025 at 2:40pm revealed that staff do not always knock on the door before entering. During an interview with CNA A on 05/29/2025 at 8:22 am revealed that she had been trained on resident rights. She said the policy for knocking was that staff were to knock on every resident's door before entering. She said that all staff were required to knock before entering the resident's room because it was the resident's home. She said that the only time staff did not have to knock was in the event of an emergency. She said that if staff did not knock the resident may feel like their privacy was being invaded. She said that the charge nurse, ADM was responsible for monitoring to ensure staff were knocking on the residents' doors. She said that the charge nurse, ADM monitored by observations. She said she had her hands full, so she did not knock. She said she should have knocked. During an interview with Activity Assistant on 05/29/2025 at 9:17 am revealed that she had been trained on resident rights. She said the policy for knocking was that staff were to knock before entering a resident's room. She said that all staff were required to knock before entering the resident's room. She said that there was not any time that the staff did not need to knock on the resident's door. She said if staff did not knock, the resident may feel bad. She said that if staff did not knock the resident may feel like their privacy was being invaded. She said that the whole staff were responsible for monitoring to ensure staff were knocking on the residents' doors. She said that staff monitored by observations. She said she did not knock because her hands were full, so she did not knock. She said she did not know why she did not knock on Resident #52 and Resident #190. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 2 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 An interview with the ADM on 05/29/2025 at 11:20 a.m., revealed that he and staff had been trained on resident rights. He said the policy was to knock on the door and wait for a response enter. He said that it was important for staff to knock on the residents' door all the time before entering. He said that most residents might not care but others may feel like it was an invasion of privacy. He said the only time staff did not need to knock on the resident's door was in an emergency. He said that the charge nurse was to monitor to ensure that staff were knocking on the door. He said the management monitored knocking by observation of the halls. He said he did not know why staff were not knocking on residents' doors before entering. During an interview with the DON on 05/29/2025 at 11:34 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, identify themselves and ask permission to enter if possible. She said that staff were to knock all the time before entering the resident's room. She said she did not know how the resident feels when staff do not knock before entering. She said staff did not have to knock when the staff knew the resident would not hear them or in an emergency. She said that the charge nurse was responsible for monitoring to ensure staff were knocking before entering. She said that the charge nurses monitored it by doing observations. She said that she did not know why the staff did not knock before entering. Record review of Resident Rights revised 05/14/2019 revealed the resident had a right to personal privacy and confidentiality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 3 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 (Resident #136) of 3 residents reviewed for ADLs. Residents Affected - Few The facility failed to provide Resident # 136 with adequate showers/baths. Resident # 136 received three (3) showers/baths within a 2-week timeframe of May 2025. This failure could place residents who required assistance for bathing at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #136's face sheet dated 05/29/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute diastolic (congestive) heart failure (a stiff left ventricle, which prevents the heart from relaxing between beats.), hypothyroidism unspecified (a condition in which the production of thyroid hormone by the thyroid gland is diminished), permanent atrial fibrillation (a long-term condition where the heartbeat does not return back to a normal rhythm.), presence of prosthetic heart value (an artificial device surgically implanted into the heart to replace a heart valve that has become damaged. The human heart has four valves, the tricuspid, pulmonary, and pulmonary, and aortic.) Review of Resident #136's most recent MDS, dated [DATE], reflected a BIMS score of 15, indicating intact cognition. Review of Resident #136's care plan reflected a focus initiated 05/19/25 Resident #136 will have the following status ADL's and preferences that need staff attention, understanding, and possible assistance for my deficit These will appear as interventions so that they will flow to Kardex for staff to see. Basic problem is deficit of staff's knowledge of residents ADL's preferences and routines. Record review of Resident #136's shower log from 05/15/25 through 05/27/25 reflected the following: 1. Resident #136 showers/bathe self-task in the electronic monitoring log dated 05/15/25 indicated bath given to Resident #136. 2. Resident #136 showers/bathe self-task in the electronic monitoring log dated 05/17/25 indicated bath given to Resident #136. 3. Resident #136 showers/bathe self-task in the electronic monitoring log dated 05/22/25 indicated bath given to Resident #136. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 4 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 4. Level of Harm - Minimal harm or potential for actual harm Resident #136 showers/bathe self-task in the electronic monitoring log dated 05/24/25 indicated bath was refused by resident#136. Residents Affected - Few 5. Resident # showers/bathe self-task in the electronic monitoring log dated 05/17/25 indicated bath was refused by the resident. Interview on 05/28/25 with Resident #136 at 1:40 pm she said staff treats her wonderful. She stated she received a shower Wednesday 5/15/25. She stated her shower days were Tuesday, Thursday, and Saturday. She stated they skipped Saturday 5/24/25. She stated she took a sponge bath since the sprinkler was off. She stated they haven't changed her sheets since her shower 5/21/25. The resident appeared to be cleaned and well kept. Interview on 05/28/25 with Resident #136 family member at 1:45 pm reflected Resident # 136 never refused a shower. He stated they were advised there was an issue with the sprinklers and the water was off. Interview on 05/29/25 with CNA B at 2:05 pm reflected CNAs, and the shower aide was responsible for providing showers. She stated the charge nurse was responsible for making sure the showers were done. She stated residents are provided a shower on a regular basis, that can set them up for infections and they can start smelling. She stated if the resident refuse shower she will ask 3 times to make sure before advising the nurse the resident refused. She stated she must give a shower, unless a resident goes out on an appointment on their shower days, they let the 2 to 10 shift know they need a shower. Interview on 05/29/25 with CNA C at 2:15 pm reflected CNAs were responsible for providing showers. The CNA's and the charge nurse were responsible for making sure the showers were done. She stated shower days were set up for residents. They may take showers on Mondays, Wednesdays, or Fridays or they take them Tuesdays, Thursday, and Saturdays. She stated they had a book by at the nurse's station that has the days and times the residents were scheduled to take their showers. She stated she lets her residents know when she does rounds today are their scheduled shower days. She stated if the resident doesn't get a shower, it can cause skin breakdown, flakey skin. She stated if the resident refuses a shower, she reports it to her charge nurse. She stated she try and offer a shower 3 times and then she will let the charge nurse handle it from there. She stated the nurse has had to contact family members to get the residents to take showers. She stated if something happens and she cannot provide a shower to the resident, she let her nurse know so the next shift can provide a shower. She denied any resident hasn't received a shower. She stated they change linen on their shower days. If there were stains or wet their sheets, or spill something on their sheet she will change them. She stated if a resident has been there for a week they should have at least 3 showers. Interview on 5/29/25 with Shower Aide A at 2:27 pm reflected the shower aide gives men showers and some women and the CNAs were assigned to the showers of the residents he doesn't do. On station one he does men on and on station 2 he does men and women. He stated the charge nurse fills out a shower sheet every day. If the residents refuse, he will report it to the nurse. She will ask the residents and if they refused, she would mark it on the shower sheet. Showers were set up Mondays, Wednesdays, and Fridays and Tuesdays, Thursdays, and Saturdays. In the shower book, it was written in blue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 5 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 - Few for him to do those resides. Hospice was written in red at the bottom of the shower book. If the residents' names were not in the red or blue, the CNA on the floor were responsible. He stated there should not be an excuse for residents not to receive their showers. He said someone else will be assigned to provide the showers, if 6-2 do not do it the 2-10 will do it. He denied the residents will go without their shower. If the next day, he found out they had not been given a shower he will provide a shower to them. The resident's linen was changed every shower day. If they ask for their linen to be changed, they will change it. If they refuse a shower they will change their sheets. Interview on 5/29/25 with DON A at 2:40 pm reflect her expectations were for them to do their job as a nurse according to the state and CMS guidelines. CNAs were responsible for providing showers. She stated the showers days were Mondays, Wednesdays, and Fridays and Tuesdays, Thursdays, and Saturday's morning and afternoons. She stated if residents were not provided a shower, they can get infection, skin breakdown, or heat rashes. The aid goes in the resident rooms, advised the resident today is their shower day and give them around about time of when their shower will be given. If the resident refuses, the nurse will go down and let them know they need to have a shower because they do not want skin breakdown. The resident may agree to take the shower, or they may not agree. They cannot force them because it was their right, they had family intervene at times, but they try not to result to that but sometimes that works. All staff are responsible for the care of all residents. She stated her job was to make sure everyone was doing what they are doing. Review of the Activities of Daily Living (ADLs), CSG Nursing Policy and Procedure undated states: The facility will be based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 2. Transfer and ambulation. 3. Toileting. 4. Eating to include meals and snacks. 5. Using speech, language, or other functional communications systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 6 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care (Resident #7). Residents Affected - Few The facility failed to ensure Resident #7's oxygen mask tubing was changed out and dated on 04/20/25. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #7's 5/29/2025 face sheet indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses hypertensive heart disease without heart failure (a long-term condition that develops over many years in people who have high blood pressure. It's a group of medical problems ? like heart failure and conduction arrhythmias ? that can happen when your high blood pressure (hypertension) is unmanaged), Alzheimer's disease with late onset (a common form of dementia that starts after the age of 65. It can cause memory and cognition issues, impaired judgment, and other symptoms as it progresses.), encounter for palliative care (encounters for comfort care, end of life care, hospice care and terminal care for terminally ill patient), age related cognitive decline (the gradual loss of thinking and memory abilities that occur during aging). Record review of Resident #7's annual MDS dated [DATE] indicated he had a BIMS score of 00 which meant sever impairment. Record review of Resident #7's care plan printed 02/27/25 indicated he was at risk for heart failure, congestive, diastolic, systolic, or mixed places at risk for decreased cardiac output, activity intolerance, excess fluid volume, impaired gas exchange/ineffective breathing patterns. Interventions: to provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered. Record review of Resident #7's order summary report indicated he had orders as followed: 1. Change O2 tubing Q week every night shifts every Sunday with a start date of 06/01/25 and no end date. 2. May use O2 @ 2-4 Liters via nasal canula for oxygen lower than 90% PRN. Ween as tolerated with no start date but a revision date of 02/27/2025. During an observation on 05/27/25 at 12:25 PM Resident #7's oxygen tubing was dated 04/20/25. Interview on 5/29/25 with DON A at 03:27 PM reflected the nurses were responsible for changing the nasal cannula tubing to the oxygen concentrator weekly. When the distilled canister is empty, it is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 7 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few refilled would be the time that they are cleaned. She stated distilled water was not required for a concentrator it was just to moisten the air. The cannula is changed weekly. She stated they do not date the cannula; it must have been hospice. Interview on 5/29/25 with Infection Control Nurse A at 03:35 PM reflected the canisters they currently use were prefilled and that they were changed when empty and dated when opened. He stated water in the canisters were not required that their practice was to utilize it for comfort. He stated that there would not be any serious injury for a Residents concentrator not having a filled canister that only if sensitive to dry air would they have a possible nosebleed. He stated in the situation involving Resident #7 he was on oxygen previously and left the ordering hospice and came off the oxygen. He stated the new Hospice care placed him back on Oxygen concentrator as they provided the device, but they did not inform the facility. He stated that now that they know about him being placed on the concentrator the canister has been changed. The administrator was asked if there was a policy regarding the concentrator and cannula and he provided the manufactured booklet. Direct Supply Attendant Owner 's Manual Maintenance section regarding the oxygen nasal cannula stated: Follow the nasal cannula manufacture's manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 8 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biological were stored under proper temperature for 1of 2 Medication Rooms (Medication room [ROOM NUMBER]) reviewed for medication storage. The facility failed to ensure the correct temperature for the storage of refrigerated medications for 9 days in Medication room [ROOM NUMBER]. This failure could place residents receiving medication at risk for lack of drug efficacy. Findings included: During an observation and record review of the Refrigerator Temperature Log for the month of May 2025 in Station 2, Medication room [ROOM NUMBER] on 05/28/2025 at 2:00PM temperature readings were below 36 degrees Fahrenheit for 18 of 27 days were recorded. The out-of-range temperatures read from 30 degrees Fahrenheit to 34 degrees Fahrenheit. During an interview with the DON on 05/29/2025 at 9:10AM the DON stated it was the night nurses' responsibility to check the temperatures of the refrigerators and document them on the log. The DON explained the facility had been utilizing PRN staff on night shift and this could have led to the failure to check the refrigerator temperatures. The DON explained it was their process to notify Maintenance if the temperatures were out of range so they can be adjusted. She also stated the medications could be moved to another refrigerator if the temperatures cannot be modulated. The DON stated a negative outcome of having medications stored below their recommended storage temperatures could lead to the medication being compromised and losing their efficacy. During an interview with Pharmacist on 05/29/2025 at 9:15AM the Pharmacist stated in his professional opinion, temperatures of 30 degrees did not adversely affect the medications being stored. During an interview with the Administrator on 05/29/2025 at 2:15PM, he stated the refrigerator temperatures were to be checked and documented each night. If there were out of range temperatures, the staff were expected to notify Maintenance. Record review of the policy entitled; Storage of Medication Requiring Refrigeration read: The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity: a. Room temperature refers to temperature maintained between 68 - 77 degrees F. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 9 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Refrigerated refers to temperature maintained between 36 - 46 degrees F. Level of Harm - Minimal harm or potential for actual harm c. In a cool place means refrigerated unless the medication's label states otherwise. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 10 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards reviewed for food service safety in the reviewed 1 of 1 kitchen. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, maintaining unsanitary kitchen equipment, and storage areas. These failures can place residents at risk for foodborne illness. Findings included: Observation in the kitchen on 5/27/2025 at 8:35 AM of the coolers reflected the following: Sausage was in a sealed bag but was undated. Turkey Lunch meat sealed in a bag was dated 5-16-2025 with no discard date. Smoked ham lunch meat in a bag that was opened. Cheese in a sealed bag that was not dated. Cabbage were in a sealed bag that was not dated. Half of an avocado was in a sealed bag that was not dated. Pico in a plastic container had a use-by date of 5-15-2025. The drink container with a red lid had no label or date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 11 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 Butter was opened that was not sealed. Level of Harm - Minimal harm or potential for actual harm Observation on 5/27/2025 at 8:48 AM of the Pantry reflected the following: - Residents Affected - Some Dented Manwich can on the shelf. Dented Hunts tomato sauce on the shelf. Macaroni in a sealed bag with a date that was unreadable. Sprinkles dated 12-28-2024 on the expired line. Vanilla wafers in a sealed bag with no date. Observation on 5/27/2025 at 8:57 AM of the freezer reflected the following: Frozen Hot Pockets dated 4/22 with no year and no discard date. Frozen pork Chops dated 5/20 with no year and no discard date. Frozen Chicken patties with an unreadable date on the sealed bag. Observation on 5/27/2025 at 9:14 am of the kitchen reflected the following: The drawer containing serving utensils was dirty and had debris in it. An interview on 5/29/2025 at 9:53 AM with the DM, she stated that when an item was put into the cooler, it should be labeled with what was in the bag unless you can tell what's in the bag from looking at it. The DM stated that when a bag was put in the cooler or freezer, it should have the date put in, with the expiration date. The DM stated that if she sees an out-of-date item, she throws it away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 12 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 All foods should be sealed when put into the cooler or freezer. Dented cans were placed in the back and was sent back for credit. If residents were served out-of-date food, they were at risk of foodborne illnesses. An interview on 5/29/2025 at 10:03 AM with CK A, she stated that when she puts something in the cooler, she will put the date on the item, and by the 3rd day, it was discarded. CK A stated that dented cans were to be removed from the pantry and placed in the area designated for dented cans. CK A stated that all out-of-date food was thrown away. CK A stated that if residents were served out-of-date food, they could get sick. An interview on 5/29/2025 at 10:10 AM with DMA, she stated that if an item were put into the cooler or the freezer, it should be in a sealed bag, labeled, and dated. DMA stated that items in the cooler and freezer should be sealed. Dented items were removed and placed behind the door, and the cans were sent out. Residents could get sick from being served out-of-date food. An interview on 5/29/2025 at 10:10 AM with the CK, CK stated that when an item was opened, it should be sealed, labeled, and dated with the correct date and expiration date. The CK stated if he sees something out of date, he tells DM, and the item was thrown out. The CK stated that all items in the cooler and freezer should be sealed. The CK stated that if a resident was served food that was out of date, then the resident could get sick. An interview on 5/29/2025 at 1:45 PM with the ADM, ADM stated that all food items in the kitchen should be dated and labeled. The ADM stated that all food items were to be sealed correctly. The ADM stated that if an out-of-date item was used, residents could get sick. The ADM stated that when taking the temperatures of food, a new sanitation wipe should be used to clean the thermometer. Record review of the facility food storage policy read: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. 1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 °F or less for a maximum of 7 days. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a white label, the day/date of opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 13 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 5. Level of Harm - Minimal harm or potential for actual harm The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) Residents Affected - Some 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. 8. Note: prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 14 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 residents (Resident #16, Resident #38, and Resident #67) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA A conducted hand hygiene when passing resident lunch trays to Resident #16, Resident #38, and Resident #67. These failures could place residents at risk of transmission of disease and infection. Findings include: Record review of Resident #16's face sheet dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included: polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), hypertension (high blood pressure), difficulty in walking, unsteadiness on feet, weakness, need for assistance with personal care, cognitive communication deficit (problems with communication), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), kidney disease, peripheral vascular disease (abnormal narrowing of arteries), need for continuous supervision, feeding difficulty, and reduced mobility. Record review of Resident #16's Quarterly MDS dated [DATE] reflected she had a BIMS Score of 13, which indicated intact cognitive response. Record review of Resident #38's face sheet dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: cerebral infraction (long term effects of a stroke), heart failure, hypertension (high blood pressure), cyst of pancreas (small sac of fluid that grows on or inside the pancreas), hyperlipidemia (high cholesterol), weight loss, kidney disease, chronic pain, pain in left shoulder, and nausea. Record review of Resident #38's Annual MDS dated [DATE] reflected she had a BIMS Score of 07, which indicated severe cognitive impairment. Record review of Resident #67's face sheet dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #67 had diagnoses which included: hyperlipidemia (high cholesterol), hypertension (high blood pressure), dementia (memory, thinking, difficulty), heart disease, type 2 diabetes mellitus without complications (high blood sugar), anxiety (feeling of uneasiness or worry), osteoporosis (disease that weakens the bones and make them more likely to break), hyperthyroidism (excessive production of thyroid hormones), hypermetropia (nearby objects appear blurred) and presbyopia (gradual loss of the eyes focus on nearby objects. Record review of Resident #67's Quarterly MDS dated [DATE] reflected he had a BIMS Score of 12, which indicated moderate cognitive impairment. Observation of lunch hall trays on 05/27/2025 at 12:38pm revealed that CNA A did not sanitize or wash her hands between residents' meal trays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 15 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 During an interview with CNA A on 05/29/2025 at 8:27am revealed that she had been trained on infection control. She said the policy was when passing a meal tray staff were to wash their hands before starting to pass meal trays. She said staff could sanitize between meal trays. She also said that if staff sanitized their hands, then on every third meal tray staff were supposed to wash their hands with soap and water. She said all staff were supposed to wash their hands when passing meal trays. She said if staff did not use proper hand hygiene it could cause cross contamination. She said the nurses were responsible for monitoring to ensure staff were washing/sanitizing their hands. She said the nurses monitored the handwashing through observation and asking. She said she forgot to sanitize/wash her hands because she got nervous. She also said that was not an excuse she should have washed/sanitized her hands. During an interview with Infection Preventionist on 05/29/2025 at 9:36am revealed that he had been trained on infection control. He said the policy was when passing meal trays staff were to wash their hands before, sanitize between trays and on the third meal tray wash their hands again. He said all staff were supposed to wash their hands when passing meal trays. He said if staff did not use proper hand hygiene it could cause an infection. He said the nurses were responsible for monitoring to ensure staff were washing/sanitizing their hands. He said the nurses monitored the handwashing through observation. He said thought CNA A got nervous. During an interview with the ADM on 05/29/2025 at 11:23am revealed that he had been trained on infection control. He said the policy was when passing meal trays staff were to wash or sanitize their hands. He said all staff were supposed to wash their hands when passing meal trays. He said if staff did not use proper hand hygiene it could get a resident sick or spread germs. He said all of management was responsible for monitoring to ensure staff were washing/sanitizing their hands. He said management monitored by walking around. He said CNA A got nervous and realized after that she did not wash or sanitize between meal trays. During an interview with the DON on 05/29/2025 at 11:39am revealed that she had been trained on infection control. She said the policy was when passing meal trays staff were to wash their hands before, sanitize between trays and on the third meal tray wash their hands again. She said all staff were supposed to wash their hands when passing meal trays. She said if staff did not use proper hand hygiene it could cause an infection or spread an infection. She said the infection preventionist was responsible for monitoring to ensure staff were washing/sanitizing their hands. She said he monitored by tracking infections and observations. She said CNA A got nervous. Record review of handwashing for food safety not dated revealed Control the transfer of bacteria in your kitchen by knowing when and how to wash your hands and following these five steps: 1. Wet your hands with clean, running water (warm or cold), turn off the tap and apply soap. 2. Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers and under your nails. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 16 of 17 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. Level of Harm - Minimal harm or potential for actual harm 4. Residents Affected - Few Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel. Here are crucial moments when you should remember to wash your hands: o Before, during and after you prepare a meal. Record review of Infection Prevention & Control Program revised on 05/2028 revealed: 1. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. b. Staff shall wash their hands before and after performing resident care procedures. c. Hands shall be washed in accordance with our facility's established hand washing procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 17 of 17