Health inspection·January 18, 2024

F 0578 revealed physician orders listed as full code. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's care plan dated [DATE] revealed a care plan goal for Full Code and the intervention was I do want CPR. Residents Affected - Few Record review of Resident #6's Out of Hospital Do Not Resuscitate form dated [DATE] revealed it was completed by a qualified relative, two witnesses, Physician's Statement, and a physician. Record review of the EHR of Resident #13's current undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include unspecified symptoms and signs involving the nervous system, gastro-esophageal reflux (acid reflux), calculus of kidney (kidney stones), hypertension (high blood pressure), cerebral infarction unspecified (stroke), and osteoarthritis (arthritis). Additionally, the advance directive was listed as full code. Record review of the EHR of Resident #13's physician order summary dated [DATE] revealed physician orders listed as full code. Record review of Resident #13's care plan dated [DATE] revealed a care plan goal for Full Code and the intervention was I do want CPR. Record review of Resident #13's Out of Hospital Do Not Resuscitate (OOH-DNR) form dated [DATE] revealed it was completed by a qualified relative, Physician's Statement, and signed by a physician. During an interview on [DATE] at 3:20 PM, LVN A said she was not aware the was a change of the advance directive for Resident #6 from Full Code to Do Not Resuscitate (DNR). She said she was not aware there was a signed Out-of-Hospital Do Not Resuscitate (OOH-DNR) document in Resident #6's physical paper chart. She said she was aware Resident #6 was receiving hospice services. She said she did not know if it was possible for a resident to receive hospice services and still have an advance directive of full code. She said herself and all nursing staff prefer to use the Electronic Health Record (EHR) instead of the resident's physical paper chart when referring to a resident's medical records and information. She said she and all other nursing staff would refer to the EHR to verify the advance directive for a resident and would follow that directive in the event of a medical emergency (cardiac emergency). She said all facility staff (including but not limited to nursing staff, other direct care staff, business staff, administrative staff) prefer to use EHR instead of looking in the physical paper chart as they were in the process of making all records electronic and paperless. She said the only time she and other nursing staff would look in the physical paper chart to obtain information on a resident's advance directive, was if it was not listed in the EHR. She said herself, ADON, and DON were responsible for updating advance directives in all the resident's EHR's. She said the system for ensuring all advance directives were correctly documented in the EHR was that when the CN receives the completed OOH-DNR form, she makes a copy of it, and puts the copy in a designated folder that they all refer to and would update the resident's advance directive in the EHR. She said then she puts the original copy of the OOH-DNR in the Business Office mailbox who scans and uploads the advance directive into the EHR documents section, and then the original OOH-DNR would be filed in the resident's physical paper chart. She said the business office staff only uploads the OOH-DNR electronic file into the EHR, however they do not update the advance directive status in the EHR. She verified resident #6's OOH-DNR form was not uploaded into the EHR and the EHR also shows the resident's advance directive was listed as full code in the Care Plan, physician orders, and face sheet. She said she does not know why the advance directive in the EHR was incorrect for Resident #6. She said she was trained to look for advance directives in the resident's EHR and to call 911 in the event (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 2 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of a medical emergency. She said she was not aware the advance directive for Resident #6 had changed to DNR status. She said the potential negative outcome of the incorrect advance directive being in the EHR was that nursing staff may respond incorrectly when a resident has a medical emergency and could either cause an injury by administering CPR to a resident with DNR orders or a resident with an advance directive of full code status could die because they did not receive CPR, and that would be negligent on their part. She said there were times that a person can sustain injuries such as bruising and broken bones during the process of receiving CPR and those injuries would be unnecessary for residents who have an advance directive of DNR. During an interview on [DATE] at 4:20 PM, LVN B said that she's the Charge Nurse (CN) for all residents that live on Hall 3, which includes Resident #6 and Resident #13. She said she has worked at the facility for a total of 14 years. She said in the event of a medical emergency she would first refer to the resident's physical paper chart to look for their advance directive. She verified the EHR shows Resident #13's advance directive was listed as full code. She said the business office staff scan and upload the OOH-DNR forms into the EHR for all residents. She said the business office staff scan upload the OOH-DNR form into the EHR and then nursing staff enter the advance directive status of either full code or DNR status in the EHR during the resident's initial admission. She said she was only responsible for updating the advance directives on residents that were returning from the hospital. She said during the readmission process, if she was given an OOH-DNR form, she would update the advance directive status in the EHR, then she would put the original form in the business office staff mailbox, who would then scan and upload the document into the EHR, then or original OOH-DNR form would be filed in the physical paper chart. She said she does not know if Resident #13's OOH-DNR was completed during the initial admission or if it was completed during a readmission. She said that she does not know why Resident #13's advance directive listed in the EHR was incorrect. She said she was aware that resident #13's advance directive was DNR. She said she was trained that on the same day the resident was readmitted in the facility while she is completing the readmission process in the EHR record that she must update the advance directive on the same day of the readmission. She said she was concerned that the advance directive in the EHR was incorrect. She said this was a concern because if staff only refer to the EHR when looking for the resident's advance directive during a medical emergency, then this would show that Resident #13 was a full code and then the staff would respond incorrectly by administering CPR to the resident. She said she was also concerned because once staff start administering CPR on a resident, they cannot stop until a doctor instructs them to stop, even if it was later discovered during that process that the resident's advance directive was DNR. She said a potential negative outcome of the advance directive being incorrect in either the EHR or the physical paper chart was that staff would respond incorrectly and possibly administer CPR on a DNR resident or not administer CPR on a full code resident and that resident could die. She said another potential negative outcome of this was that in both scenarios they and/or the facility would be at risk of facing a lawsuit and other legal consequences. During an interview on [DATE] at 12:30 PM, the DON said she has worked at the facility for 27 years. She said she believes staff would first look in the physical paper chart and then refer to the EHR on the front screen of the resident when trying to locate a resident's advance directive. She said her expectation was for staff to document and/or update a resident's advance directive in the EHR immediately when the completed OOH-DNR form was received from the physician. She said the advance directive should be documented on the physician orders and the care plan in both the EHR and physical paper chart. She said advance directives should be changed if the physician instructs them to change it or if a resident request it to be changed. She said she was not aware that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 3 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few advance directives documented in the EHR and physical paper chart for Resident #6 and Resident #13 were incorrect until she was notified by her staff that the surveyor brought it to their attention, which has since been corrected. She said the system for them to ensure advance directives were correct was that during the initial admission processing of a resident, the business manager scans the OOH-DNR form into the EHR if it has been completed correctly, then the CN writes an order to update the advance directive, then the advance directive status was updated in the EHR. She said then the OOH-DNR form gets filed in the resident's physical paper chart. She said the CN was responsible to update or enter advance directives into the EHR for residents during both the initial admission as well as readmission process. She said the orders for Resident #6 and Resident #13 did not get written by the CN, which was why their advance directives were incorrect. She said staff were trained that the business manager scans the OOH-DNR form into the EHR if it has been completed correctly, and then the CN writes an order to update the advance directive, and then the CN updates the advance directive in the EHR. She said herself, the ADON, and the ADM were responsible for training staff. She said the facility policy for advance directives was that the CN writes the order to update the advance directive in the EHR as soon as the OOH-DNR form was received from the physician and verified that it was filled out correctly. She said potential negative outcomes of advance directives being incorrect in the EHR and/or the physical paper chart were that a resident with a full code advance directive would not get CPR when they were supposed to or a resident with a DNR advance directive would receive CPR when they were not supposed to. During an interview on [DATE] at 12:45 PM, the ADM said she has worked at the facility for 11 months. She said staff would look in the EHR first when trying to locate a resident's advance directive in the event of a medical emergency. She said her expectation was for staff to upload the OOH-DNR form and update the advance directive in the EHR immediately once they have verified the form was received and filled out correctly by the physician. She said the OOH-DNR form must be uploaded in the documents section in the EHR and then the original must be filed in the resident's physical paper chart. She said the advance directive status must also be documented in nurse progress notes and the report log. She said she was not aware that advance directives documented in the EHR and physical paper chart for Resident #6 and Resident #13 were incorrect until she was notified by her staff that the surveyor brought it to their attention. She said the system in place to ensure advance directives were documented correctly was that the business office manager uploads the OOH-DNR form into the EHR, then it was sent to the ADON or DON, who then document the advance directive in the EHR, and then file the OOH-DNR form in the resident's physical paper chart. She said herself, the ADON, and the DON were responsible for training staff. She said the facility policy was that the DON notifies the physician of the advance directives so the orders can be documented in the resident's record and care plan, then the resident's wishes were communicated to staff. She said facility policy also stated the OOH-DNR form was uploaded and documented in the EHR as well as in the resident's care plan and then the Inter-disciplinary Team must be notified of any changes to a resident's advance directive. She said a potential negative outcome of the advance directive being incorrect on the face sheet, care plan, EHR, physical paper chart, and physician orders was that staff would not be respecting resident rights if they were to respond incorrectly during a medical emergency. She said a resident with an advance directive of DNR should not receive CPR and a resident that was full code should receive CPR. She said responding incorrectly could result in an unnecessary and preventable death to a resident who was full code or injuries and unnecessary health problems to a resident that was DNR. Record review of the facility policy, Advance Directive, Revised [DATE], revealed the following documentation: Applicability: this policy sets forth the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 4 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 procedures relating to Advance Directives Level of Harm - Minimal harm or potential for actual harm Policy Statement Residents Affected - Few The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members, and/or his or her legal representative about the existence of any written advance directives. If the Resident Has an Advance Directive 1. If the resident or the resident's representative has executed one or more advanced directive(s) or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advanced directives (or changes in advanced directives) so that appropriate orders can be documented in the resident's medical record and plan of care. a. The attending physician is not required to write orders for which he or she has an ethical or conscientious objection. 3. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. a. Facility staff are not required to provide care that conflicts with an advance directive. b. Facility staff are not required to implement an advance directive if state law allows the provider to conscientiously object. 8. Changes or revocations of the directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of the changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. 9. The nurse supervisor is required to inform emergency medical personnel of residents advance directive regarding treatment options and provide such personnel with a copy of the advance directive or physician orders for life sustaining treatment (POLST) when transfer from the facility via ambulance or means is made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 5 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 Record review of the facility policy, Do Not Resuscitate (DNR) Order, Revised [DATE], revealed the following documentation: Level of Harm - Minimal harm or potential for actual harm Applicability: this policy sets forth the procedures relating to DNR's Residents Affected - Few Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet and maintained in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. c. The attending physician must be informed of the resident's request to cease the DNR order. 8. Inquiries concerning do not resuscitate orders/requests should be referred to the administrator, director of nursing services, or the social services director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 6 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 Resident (Resident #30) reviewed for incontinent care, in that: Resident #30 was observed to have a 16 french silicone foley catheter and had physician orders for a 14 french coude (slightly bent) catheter. This failure could affect residents by placing them at increased risk of discomfort, skin ulcerations and improper medical treatment. Findings include: Record review of face sheet for Resident #30, dated 01/17/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: lobar pneumonia (infection in one of the sections (lobes) of the lung), constipation (bowel movement problems) and retention of urine (urination problems). Review of Resident #30's physician orders, undated, revealed an order for: Change 14 French Coude catheter q(every) monthly on the 12th, with a start date of 02/12/23. Review of Resident #30's comprehensive MDS, dated [DATE] revealed Resident #30 had a BIMS score of 08 which indicated the resident's cognition was moderately impaired. The MDS also revealed Resident #30 had an indwelling catheter. Record review of Resident #30's Comprehensive Care Plan dated 01/17/24 revealed the resident had an intervention to change the foley catheter monthly, with a start date of 07/21/23. During an observation on 01/17/24 at 1:09 PM, Resident #30 was receiving incontinent care and it was noted that Resident #30's foley catheter was a 16 French silicone catheter. During an interview on 01/18/24 at 8:42 AM, LVN B confirmed that Resident #30's current foley catheter was a 16 French silicone catheter and his physician orders are for a 14 French Coude catheter. LVN B stated she did not know why Resident #30 had the wrong size catheter in, as she did not do it. LVN B stated the catheter was probably from a kit from the hospital and that was the size catheter available in the kit. LVN B stated she has been trained to insert the same size catheter as ordered by the physician. LVN B stated it was unknown what the potential negative outcome to the resident could be, but it may cause some problems. During an interview on 01/18/24 at 9:00 AM, the DON stated the nurses are trained to follow physician orders. The DON stated she did not know why Resident #30 had the wrong size catheter inserted because she did not do it. The DON stated the charge nurses, and she is responsible for ensuring physician orders are being followed. The DON stated the potential negative outcome to the resident could be he was not getting what he was supposed to have. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 7 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 01/18/24 at 9:07 AM, the ADM stated the charge nurses, the DON and the ADON are all responsible for ensuring physician orders are being followed. The ADM stated she did not know why Resident #30 had the wrong size catheter inserted. The ADM stated the potential negative outcome to the resident was the catheter could not work properly or could cause harm to his health. During an interview on 01/18/24 at 10:03 AM, the DON stated the facility did not have a policy related to following physician orders for indwelling catheters. Event ID: Facility ID: 676225 If continuation sheet Page 8 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 1 out of 48 days (12/25/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following day: 12/25/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 01/16/24 revealed there were three RNs employed at the facility. Record review time sheet for the DON dated 01/16/24 revealed no hours worked for 12/25/23. Record review time sheet for RN A dated 01/16/24 revealed no hours worked for 12/25/23. Record review time sheet for RN B dated 01/16/24 revealed no hours worked for 12/25/23. During an interview on 01/18/24 at 8:42 AM, the DON she stated she works Monday through Friday 08:00 AM to 05:00 PM. The DON stated she did not work on 12/25/23 because she was off for vacation. The DON stated she did not know why the facility did not have RN coverage as the ADM is the one who schedules for RN coverage. The DON stated it was unknown what the potential negative outcome could be because they are close to the hospital if they needed help. During an interview on 01/18/24 at 8:07 AM, the ADM stated she did not know why the facility did not have RN coverage for 12/25/23. The ADM stated maybe agency was scheduled and did not show up, she was not sure. The ADM stated the potential negative outcome to the residents could be RN responsibilities could not be performed and it was detrimental to the residents. During an interview on 01/18/24 at 12:45 PM, the ADM stated the facility did not have a policy regarding RN coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 9 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1)The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure foods were not beyond manufacturer's use dates. 3) The facility failed to ensure foods were in sound condition. 4) The facility failed to ensure food were accurately dated and labeled. 5) The facility failed to protect foods from potential contamination. 6) The facility failed to ensure staff used good hygienic practices. 7) The facility failed to ensure staff facial hair was restrained, and 8) The facility failed to ensure sanitizer levels were maintained at manufacturer's recommended levels. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observations were made during a kitchen tour on 1/16/24 that began at 1:08 pm and concluded at 1:45 PM: Chemical storage room had chemicals stored above and on the same shelves with insulated lids in boxes and boxes of silverware. The chemicals that were on the shelf were Spray Glass Cleaner, ProForce Sanitizer, and Dyna Force Foaming Decarbonate Oven and Grill Cleaner. These chemicals were stored on the top shelf of the rack and the insulated lids were below it. The documentation on the Dyna Force Foaming Decarbonate Oven and Grill Cleaner was, .Causes severe skin burns and eye damage. There were spray bottles of Monogram Glass Cleaner was stored on the shelf next to boxes of silverware. The documentation on the spray bottles was .Not for use on food contact surfaces . There was another rack in the chemical storage room that had Break Up Oven and Grill Cleaner labeled, . Causes severe skin burns and eye damage . and an aerosol can of Lysol Foam Cleaner that stated, . Caution: causes moderate eye damage . stored on the shelves. These items were stored on the shelf with food containers, above boxes of plates and containers of salt and pepper shakers. The walk-in refrigerator had thawed vanilla Mighty Shakes that had the date of 12-6 marked on the box. There was another box of chocolate Mighty Shakes that was thawed and had a date on the box of 12-12. Documentation on the Mighty Shakes cartons revealed the following, Store frozen. Thaw at below 40°F. Use thawed product within 14 days. Keep refrigerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 10 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In the walk-in refrigerator, there was a box of 16 Yoplait strawberry banana yogurt, 4-ounce containers that was labeled, Use by 16 [DATE]. Observation of the pantry revealed there was one #10 can (6 lbs. 9 oz.) of California sliced yellow cling peaches that had a large dent on the side that caused a large bent the rim. The can was stored in the can rack with other in-use cans of food. - The following interviews and observations were made during a kitchen tour on 1/16/24 that began at 4:35 PM and concluded at 6:07 PM: On 1/16/24 at 4:40 PM temperatures were taken on the steam table by Dietary staff C. While taking the temperature of the purée chicken salad, Dietary staff C cleaned the thermometer probe and then held it with her bare fingers to take the temperature. Temperatures were taken with a dial thermometer. Dietary staff B was observed handling the soiled side dishwashing sprayer and cleaning dishes. She then went directly and put away clean utensils without washing her hands between the soiled and clean operations. Puréed tomato soup was 110°F and served with a 4-ounce ladle. The surveyor asked at 4:59 PM if they had calibrated the thermometers. During an interview with the Dietary Manager on 1/16/24 at 4:59 PM, he stated, he checked the calibration of the dial thermometers last week and had requested the purchase of a digital thermometer. The facility dial thermometers were checked in comparison to the surveyor's digital thermometer in ice water. The surveyor's digital thermometer was 32.5°F and the facility's #1 dial thermometer was 23°F. The surveyor's digital thermometer read 32.7°F and the facility's #2 dial thermometer registered at 29°F. The Dietary Manager tested the quaternary sanitizer in the wiping cloth bucket, and it tested at 50 ppm with the quaternary test strips. On 1/16/24 at 5:16 PM an observation and interview were conducted. The Dietary Manager tested the quaternary sanitizer dispensed from the three compartment sink and it tested at 100 ppm. He stated the quaternary level needed to be adjusted up. Observation of the quaternary sanitizer used, Ecolab ProForce Sanitizer, stated 1 ounce per gallon of water should give the appropriate level of sanitizer. No active level was stated on the container. During an interview on 1/16/24 at 5:27 PM, the Dietary Manager stated, the online information about the ProForce Sanitizer stated the active level for the quaternary sanitizer should be 200 ppm. There was a red bucket of wiping cloth quaternary sanitizer stored on the cart shelf with plates and insulated bottoms for plates at the steam table. This bucket of sanitizer was also stored above and with Styrofoam bowls. On 1/16/24 at 5:55 PM the Dietary Manager was in the kitchen with no beard restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 11 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many - The following observations were made during a kitchen tour on 1/17/24 that began at 9:21 AM and concluded at 9:45 AM: The processor pot exterior tube was soiled with food debris. Dietary staff B was observed handling soil silverware in the dishwasher area then going directly to put away clean cups. Shed did not wash your hands between the soiled and the clean operations. The Dietary Manager was in the kitchen without a beard restraint. Dietary staff A was observed holding a container lid against her shirt, then covering the stewed vegetable container with the lid. On 1/17/24 at 9:37 AM an interview was conducted with Dietary staff B. She stated that she had not been told she needed to wash her hands between the soiled and clean operations when washing dishes. She stated that she had worked in the facility for 10 years. The walk-in refrigerator had thawed vanilla Mighty Shakes that had the date of 12-6 marked on the box. There was another box of chocolate Mighty Shakes that was thawed and had a date on the box of 12-12. Documentation on the Mighty Shakes cartons revealed the following, Store frozen. Thaw at below 40°F. Use thawed product within 14 days. Keep refrigerated. There were now 12 Yoplait strawberry banana yogurt containers in a box that was labeled Use by 16 [DATE]. The cleaners and chemicals were still stored above and with food equipment on racks as observed on 1/16/24 at 1:08 PM in the chemical storage room. - The following interviews and observations were made during a kitchen tour on 1/17/24 that began at 11:03 AM and concluded at 11:41 AM: Dietary staff A was observed puréeing foods. She placed broccoli in the processor, and then adjusted the blade with her bare hand. She then puréed the food with an unknown amount of thicker. As she was pureeing the food, she covered the hole in the lid with a paper towel with her hand. She then continued to purée, then placed the purée in a pan. The Dietary Manager was in the kitchen and had no beard restraint on. Dietary staff A took the processor parts to the dishwasher to wash. After washing, she dried the parts with a paper towel and handled the blade with her bare hands as she dried the parts. She then assembled the processor parts, added tartar sauce and fish fillets and then puréed the mixture. She opened the processor lid, then closed it and rubbed her nose and face with her bare hand. She continued to purée the mixture. She then poured the purée in a pan, and as she was pouring the mixture in a pan, she took the blade out with her bare hand, and she scraped more purée into the pan from the processor pot and blade. On 1/18/24 at 9:33 AM an interview was conducted with the Dietary Manager regarding issues found in the dietary department. He stated as far as checking the dates on foods, he and another employee he was training was responsible. Regarding the dates on the boxes of shakes, he stated that the date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 12 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many marked on the boxes was the receive date most likely the date thawed. He added he was changing the policy to label foods when they were received, and the use dates. He stated the plan was to move the plates and cups to another rack. He further stated that the dishwashing vendor had not returned his call and at this time staff were using the quaternary sanitizer but mixing it manually. He stated the issues observed in the kitchen were due to a lack of training. He stated he planned to start in-services every two weeks. He added that he had conducted in-services. He stated he was also working on dietary related policies. He stated he expected staff to perform the correct dietary procedures. He stated the Dietary Manager and staff were responsible for ensuring that dietary sanitation procedures were conducted correctly. He stated the observed dietary sanitation issues could affect the nutrition and well-being of residents and could affect them emotionally. On 1/18/24 at 9:58 AM an interview was conducted with the Administrator regarding dietary sanitation issues found in the facility. She stated the dietary sanitation issues observed occurred due to human error and staff overlooking those things. She stated Dietary Manager and Administrator were responsible for ensuring dietary sanitation procedures were carried out correctly. She stated resident health could be in jeopardy, definitely with the outdated foods, as a result of the dietary sanitation issues observed. She added she expected staff to follow policy. Record review of the Dietary Staff Meeting Minutes dated 12/6/23, revealed a subject covered in the meeting were dates and labels. Those attending the meeting were Dietary staff A, B and C. Record review of the 3 Compartment Sink Log (chemical sanitation) for January 2024 revealed the following documentation, . Quaternary value should be 200 ppm. Sanitize temperature should be 75-120°F . Record review of the online Ecolab Proforce Sanitizer label revealed the following documentation, ProForce Sanitizer is an effective sanitizer at 200 PPM active quaternary for use on food contact surfaces in 500 PPM hard water. Record review of the facility policy, titled Chapter 3: Food, Production and Food, Safety, 3-22, 2023, revealed the following documentation, Policy and Procedure Manual. Food Storage. Policy: sufficient storage facilities will be provided to keep foods, safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure. 4. Chemicals must be clearly labeled, kept in original containers, when possible, kept in a locked area and stored away from food. 13. Refrigerated food storage. f. All foods should be covered, labeled and dated and routinely, monitored to assure that foods (including leftovers) will be consumed by their use by dates, or (where applicable) or discarded. h. Refrigerated food should be stored upon delivery and careful rotation procedures should be followed . Record review of the facility policy, titled Chapter 3: Food, Production and Food Safety, 3-32, 2023, revealed the following documentation, Policy and Procedure Manual. Resource: Taking Accurate Temperatures. Choosing a Thermometer. Start with an accurately calibrated thermometer that is in good (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 13 of 14 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many working condition. There are many types of thermometers available. Check state regulations for more specific guidelines. Calibrating The Thermometer. For all thermometers, follow the manufacturer's directions for calibration. Taking Accurate Temperatures Using Metal Stem Thermometers. 1. To take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is the metal stem type, numerically, scaled and accurate to plus or -2°F is needed. Record review of the facility policy titled Chapter 4: Sanitation and Infection Control, 4-1, 2023, revealed the following documentation, Policy and Procedure Manual. Food, Safety, and Sanitation. Policy: all local, state and federal standards and regulations will be followed to assure as safe and sanitary food and nutrition services department. Procedures . 2. Employees. a. All staff will be in good health, will practice, good personal hygiene and will use safe food handling practices. c. Employees are required to have their hairstyle so that it does not touch the collar, and to wear clean aprons, clothes, and closed toed shoes. [NAME] nets are required when facial hair is visible. d. Employees will wash their hands just before they start to work in the kitchen, and after smoking, sneezing, using the restroom, handling, poisonous compound, or dirty dishes, and touching face, hair, other people, or surfaces, or items with potential for contamination. Record review of the facility policy titled Chapter 4: Sanitation and Infection Control, 4-4, 2023, revealed the following documentation, Policy and Procedure Manual. Employee Hygiene for Food Safety. Policy: all food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Procedure: all employees will 1. Wear hair restraint, (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. 2. Wash hands before handling food, using posted handwashing procedures. 7. Avoid touching mouth or face while preparing food (and wash hands if contaminated) . Record review of the facility policy titled Chapter 4: Sanitation and Infection Control, 4-8, 2023, revealed the following documentation, Policy and Procedure Manual. Handwashing. Policy: employees will wash their hands as frequently as needed throughout the day, using proper handwashing, procedures . Procedure: hands and exposed portions of arms, (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands. f. After handling solid equipment are utensils. g. During food preparation, as often is necessary to remove soil or contamination and prevent cross contamination when changing tasks. j. After engaging in other activities, that contaminate the hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 14 of 14