Inspection·September 29, 2023

F 0641 neuropathy with order date 10/6/21 and no end date. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #34's Order Summary Report revealed the resident was not treated with insulin. Residents Affected - Few During an interview on 9/28/23 at 11:52 a.m., the DON revealed the MDS, and the care plan were the responsibility of the MDS Coordinator. The DON stated Resident #34 had diabetes and was treated with metformin and glipizide. The DON further stated she was not certain if Bydureon was insulin but confirmed it was used to treat diabetes. The DON stated, if the MDS was incorrectly coded then it would be considered inaccurate and it would not reflect the resident correctly. During an interview on 9/28/23 at 12:05 p.m., the MDS Coordinator revealed Resident #34 was a diabetic and had been treated with Bydureon injection she believed to be a form of insulin. The MDS Coordinator revealed she was not aware Bydureon injection was not an insulin and was marked in error on the MDS assessment. The MDS Coordinator stated the error on the MDS assessment did not truly reflect the resident and the MDS assessment was used for reimbursement and to tell the story of the resident. The MDS Coordinator stated the RAI manual was used to develop/complete the MDS. Record review of the medication prescribing information for Bydureon injection, revision date 1/2012 revealed in part, .Bydureon is an extended-release formulation of exenatide, administered as an injection once every seven days (weekly) .Bydureon is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus in multiple clinical settings .Bydureon is not a substitute for insulin . Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 2 of 8 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure their medication error rate was not 5 percent or greater and had a medication error rate of 13.16% percent with 38 medication administration opportunities observed with 5 errors for 2 of 3 residents (Residents #6 and #35) and 1 of 2 (Medication Aide A) reviewed for medication administration, in that: Residents Affected - Few Medication Aide A administered an expired medication to Resident #6 and administered medications to Resident #35 outside parameters as ordered by the physician. These deficient practices could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order. The findings included: 1. Record review of Resident #6's face sheet dated 9/28/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, hypertensive heart disease without heart failure, hypertension (high blood pressure) and need for assistance with personal care. Record review of Resident #6's most recent quarterly MDS assessment, dated 8/24/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #6's comprehensive care plan, revision date 5/8/23 revealed the resident had hypertension with interventions that included to give medications as ordered. Record review of Resident #6's Order Summary Report, dated 9/28/23 revealed the following: -Norvasc tablet 5 mg (amlodipine besylate) give 1 tablet by mouth one time a day for hypertension with order date 6/24/22 and no end date Record review of Resident #6's MAR for September 2023 revealed the following: - Norvasc tablet 5 mg (amlodipine besylate) give 1 tablet by mouth one time a day for hypertension scheduled for 7:30 a.m. Observation on 9/28/23 at 7:52 a.m., during the medication pass revealed Medication Aide A administered 1 tablet of Norvasc tablet 5 mg (amlodipine besylate) with expiration date 6/2023 to Resident #6. During an interview on 9/28/23 at 7:56 a.m., Medication Aide A revealed Resident #6's medications were provided to the facility by the family and were checked by the charge nurse or the ADON for expiration dates before they were placed in the medication cart. Medication Aide A confirmed the Norvasc tablet 5 mg (amlodipine besylate) medication was expired. Medication Aide A then revealed the medications in the medication cart should be checked for expired medications by the medication aide or whoever was using the medication cart. Medication Aide A revealed, expired medications could result in the loss of therapeutic effect if given past the expired date. 2. Record review of Resident #35's face sheet dated 9/28/23 revealed a [AGE] year old male admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 3 of 8 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 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 0759 Level of Harm - Minimal harm or potential for actual harm to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, pure hyperglyceridemia (high concentration of triglycerides, most abundant fatty molecule in most organisms, in the blood), anemia (condition in which the blood does not have enough healthy red blood cells), hyperlipidemia (high cholesterol), difficulty in walking, and need for assistance with personal care. Residents Affected - Few Record review of Resident #35's most recent quarterly MDS assessment, dated 8/21/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #35's comprehensive care plan, revision date 5/8/23 revealed the following: -resident had congestive heart failure and hypertension with interventions that included to administer hypertensive medications as ordered, metoprolol -resident had potential for weight loss due to anemia with interventions to administer medications as ordered, ferrous sulfate -resident had hyperlipidemia/hypercholesterolemia with interventions that included to administer medication as ordered, fenofibrate Record review of Resident #35's Order Summary Report, dated 9/28/23 revealed the following: -Amantadine tablet 100 mg, give 1 tablet by mouth one time a day for mild motor symptoms with order date 3/1/21 and no end date -Fenofibrate tablet 145 mg, give 1 tablet by mouth one time a day for elevated triglycerides with order date 6/10/21 and no end date -Ferrous Sulfate tablet 325 mg, give 1 tablet by mouth one time a day related to anemia with order date 6/30/21 and no end date -Metoprolol Succinate ER tablet extended release 24-hour 100 mg, give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure with order date 12/2/22 and no end date Record review of Resident #35's MAR for September 2023 revealed the following: -Amantadine tablet 100 mg, give 1 tablet by mouth one time a day for mild motor symptoms scheduled for 7:00 a.m. -Fenofibrate tablet 145 mg, give 1 tablet by mouth one time a day for elevated triglycerides scheduled for 6:30 a.m. -Ferrous Sulfate tablet 325 mg, give 1 tablet by mouth one time a day related to anemia scheduled for 7:00 a.m. -Metoprolol Succinate ER tablet extended release 24-hour 100 mg, give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure scheduled for 7:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 4 of 8 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 9/28/23 at 8:33 a.m. during the medication pass revealed Medication Aide A administered Resident #35's Amantadine, Fenofibrate, Ferrous Sulfate and Metoprolol outside parameters as ordered by the physician. During an interview on 9/28/23 at 8:47 a.m., Resident #35 revealed he had not received any medications on 9/28/23 prior to the medications administered by Medication Aide A. Resident #35 stated, I'll take my medications any time they give them to me. Doesn't matter if it's before or after breakfast. During an interview on 9/28/23 at 8:49 a.m., Medication Aide A revealed she started her shift at 6:00 a.m. and started her shift by checking the medication cart to ensure it was stocked, stocked a pitcher with ice water and then started medication pass. Medication Aide A revealed she had asked Resident #35 if he wanted his medications at the beginning of the shift but Resident #35 wanted to go to the dining room first. Medication Aide A stated, medications needed to be given as scheduled because physician's orders were supposed to be followed and if not given as scheduled the medication would not have the proper therapeutic effect. During an interview on 9/28/23 at 9:16 a.m., the DON confirmed medications were scheduled per facility policy and could be administered up to one hour before and one hour after the scheduled time. During a follow up interview on 9/28/23 at 11:41 a.m., the DON revealed there were some residents who preferred their medications after eating breakfast but Resident #35 was not one of them. The DON revealed, Resident #35 would have taken his medications whenever they were offered. The DON revealed, expired medications given to the residents could result in an adverse effect or the resident could get sick and it would not be effective if used past the expiration date. The DON revealed, medications not administered during their scheduled time could results in those medications negatively interacting with other medications and could also results in the medication not providing a therapeutic effect. The DON revealed medications not given per schedule was not following the physician's orders. Record review of the Medication Aide Proficiency Audit for Medication Aide A, dated 12/23/22 revealed Medication Aide had satisfied the requirements for passing medications, including checking medications 3 times, observing the 6 rights of medication including Right Time and checking medications for expiration dates. Record review of the facility policy and procedure titled, Medication Administration Procedures, revision date 10/25/17 revealed in part, .If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes .Defining the schedules for administering medications to: Maximize the effectiveness of the medication .The 10 rights of medication should always be adhered to .Right time . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 5 of 8 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Many 1. There was a storage container of prepared food in the reach-in cooler that was not properly sealed. 2. There was an open container of cottage cheese in the reach-in cooler without a date indicating when it should be used or discarded. 3. There were three open containers of thickened liquids in the reach-in cooler without dates indicating when they should be used or discarded. 4. There was an open 25 lb. sack of whole milk powder in the dry storage room that was rolled down and not placed in a sealed container. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 09/26/2023 at 11:17 a.m. in the reach-in cooler revealed a clear, plastic 4-quart container filled with cooked black-eyed peas. The container had a red plastic lid that did not extend to the end of the container, resulting in a gap approximately ½ between the lid and the container and exposing the contents of the container to the ambient air in the cooler and potential contamination by pathogens and bacteria. Interview on 09/26/2023 at 11:20 a.m. with the DM revealed the lid on the container did not fully cover the container, preventing the container from being tightly sealed and exposing the contents of the container to the ambient air in the cooler. The DM stated he was aware there were problems with the lids for the containers and the facility needed to procure new ones. The DM further stated all dietary employees were trained to label, date and completely seal all food stored in the coolers, and he provided training monthly. 2. Observation on 09/26/2023 at 11:30 a.m. in the reach-in cooler revealed a 5-lb. container of cottage cheese that had been opened. There was a typed label on the container with the date 09/06/2023 and written in marker was, Open 09/13/2023. There was no marking to indicate the date or day by which the cottage cheese should be used or discarded. Interview with the DM on 09/26/2023 at 11:32 a.m. revealed he acknowledged the cottage cheese was opened over ten days prior, did not have use-by date indicated by the facility, and should have been discarded to ensure it was safe from spoilage. 3. Observation on 09/26/2023 at 11:35 a.m. in the reach-in cooler revealed a 46 oz. container of thickened orange juice, a 46-oz. container of thickened lemon-flavored water and a 46-oz. container of thickened sweetened tea. On the thickened orange juice was written in marker, 8/16/2023. On the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 6 of 8 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 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 thickened lemon water there was a typed label reading 9/13/2023. On the thickened sweet tea was a typed label reading 9/06/2023. Interview with the DM on 09/26/2023 at 11:36 a.m. revealed he acknowledged the thickened liquids did not have use-by dates but did not believe thickened water, tea and juice were subject to spoilage. Residents Affected - Many 4. Observation on 09/26/2023 at 11:40 a.m. in the dry storage room revealed a 25 lb. paper sack of powdered milk. The sack had been opened and was rolled down. It was not placed in a sealed container to prevent potential contamination from rodents or pests. Interview on 09/26/2023 at 11:41 a.m. with the DM revealed he acknowledged the sack of powdered milk had been opened and not properly stored in sealed container. The DM stated not properly sealing the powdered milk made it subject to potential contamination from pests. Interview on 09/29/2023 at 9:45 a.m. with the administrator revealed all foods stored in coolers needed to be properly covered to prevent contamination from bacteria. The container of cottage cheese had been in the cooler for over ten days and should have been discarded. All foods brought into the facility are labeled with the date they are received and are marked with the date they are opened. The labels on the three containers of thickened liquids indicated the dates they were received by the facility. The administrator acknowledged all three containers had been opened and there were no labels or dates indicating the dates they were opened, and once opened, they were subject to deterioration and could potentially cause foodborne illness. The sack of milk powder in the dry storage room not placed in a sealed container after it had been opened and should have been to prevent the risk of contamination by pests. Record review of facility policy IC00-8.0 Food Storage and Supplies, Dietary Services Policy & Procedure Manual 2012, revealed: 3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 9. Perishable items that are refrigerated are dated once opened and used within 7 days. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Review of product storage instructions from the manufacturer of the thickened orange juice, water and sweet tea revealed all three products had the same storage instructions: Refrigerate after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 7 of 8 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 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 opening and use within 7 days. https://lyonsreadycare.com/collections/dysphagia/products/thickened-orange-juice-cartons-nectar-level-2. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676242 If continuation sheet Page 8 of 8