Health inspection·March 29, 2024

F 0641 week. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's meal ticket (undated) reflected Regular diet, minced texture and soft with regular consistency. Residents Affected - Few During an interview on 03/29/2024 at 11:35 a.m. the MDS coordinator stated she made a mistake and considered the other parts of Resident #6's diet such as fortified shakes as a therapeutic diet, and she marked hospice services, but not in the section that indicated current services for the resident. She stated MDS accuracy was important due to it leading to the resident care plan and care could be missed. During an interview on 03/29/2024 at 12:50 p.m. the DON stated the MDS nurse is accountable for the MDS's and she reviewed them, but the MDS nurse was the one who signed them for accuracy. She stated Resident #6's MDS was inaccurate because he was on a regular diet and not a therapeutic one, and he was on hospice services. She said this was important because the MDS directed the care reflected in the resident plan of care. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 2 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 residents (Resident #6, Resident #10) of 12 residents reviewed for care plans. 1. The facility failed to ensure Resident #6's bowel status was reflected in the resident's care plan (undated). 2. The facility failed to ensure Resident #10's code status was not reflected in resident's care plan. These deficient practices could place residents at risk of not receiving proper care and services. The findings included: 1. Record review of Resident #6's electronic face sheet dated 03/26/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve within 24 hours. It causes paralysis in face, arm, or leg usually on one side of the body, slurred speech, double vision or blindness, and loss of balance or coordination) and atherosclerotic heart disease (condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Record review of Resident #6's quarterly MDS assessment with an ARD of 02/22/2024 reflected he was always incontinent of bowel. He scored a 05/15 on his BIMS which signified he was severely cognitively impaired. Record review of Resident #6's comprehensive person-centered care plan (undated) did not reflect he was incontinent of bowel. Interview on 03/29/2024 at 09:00 a.m. with CNA D revealed he collaborated with Resident #6 since the resident was admitted and Resident #6 was always incontinent of bowel. Interview on 3/29/2024 at 11:31 a.m. with the MDS Coordinator, she stated that she was not able to locate Resident #6's bowel status in his care plan, and she did not know how it was missed. She stated the care plan communicated to other providers what type of care the resident required, and it could be missed otherwise. Interview on 03/29/2024 at 12:50 p.m. with the DON, she stated the care plans needed to address what care the resident required, and Resident #6's care plan did not address he was incontinent of bowel. She stated the care plan was a tool of communication for others about the care of a resident, and if it were not accurate, care could be missed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 3 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #10's face sheet, dated 03/29/2024, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included: cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and type 2 diabetes mellitus with hyperglycemia, muscle. Record review of Resident #10's admission 5-day MDS assessment, dated 02/27/2024, revealed the resident's BIMS score was 3, which indicated severe cognitive impairment. Record review of Resident #10's Texas OOHDNR (out of hospital do not resuscitate) form dated and notarized on 02/23/2024 and completed with physician signature on 03/11/2024. Record review of Resident #10's physician order summary, dated 03/29/2024, revealed an order dated 02/27/2024 for DNR. Record review of Resident #10's care plan, with the last care plan with an initiated date of 03/22/2024 revealed Resident #10's code status of DNR had not been care planned. During an interview on 03/29/2024 at 11:37 a.m. the MDS coordinator stated she was unable to located Resident #10's code status care plan as she reviewed the care plan. MDS coordinator further stated the SW usually completes the code status care plan and would be something the care team would review during care plan meetings. During an interview on 03/29/2024 at 12:38 p.m. the SW stated she had been waiting to get the Texas OOHDNR back signed and did not remember to initiate the care plan. The SW further stated she did typically complete the code status care plans and they were reviewed during care plan meetings. During an interview on 03/29/2024 at 12:54 p.m. the DON stated the facility has many other tools the staff use regarding care, so it was hard for answer the importance of a care plan. The DON further stated the care plan collaborates resident's care. The DON stated the facility did not have a policy regarding Comprehensive Care Plans they followed the RAI manual. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in section 2-44, Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 4 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #8 and Resident #88) reviewed for care plan revisions. 1. The facility failed to ensure Resident #8's care plan was updated to reflect she was not on contact isolation for shingles. 2. The facility failed to ensure Resident #88's care plan was updated to reflect DNR (do not resuscitate) code status. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #8's electronic face sheet dated 03/27/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: acute respiratory failure, pneumonia, dyspnea, and zoster without complications (onset date) 12/08/2023. Record review of Resident #8's significant change MDS assessment dated [DATE] did not reflect under the section of Active Diagnoses she had shingles. She was checked to have pneumonia. She was not a candidate for a BIMS which signified she was severely cognitively impaired. Record review of Resident #8's comprehensive person-centered care plan (undated) reflected Focus, Elder requires contact isolation r/t shingles. Observation on 03/26/2024 at 09:45 a.m. of Resident #8 in her room revealed there was no sign on her door or isolation bin outside of her room. She was lying in bed. During an interview on 03/26/2024 at 09:50 a.m. with Resident #8, stated she was not on isolation and she was at one time, but could not remember when. During an interview on 03/29/2024 at 11:35 a.m. the MDS coordinator stated Resident #8's care plan should not reflect she was on contact isolation for shingles. She stated, she did not recall when the resident was on contact isolation, but the care plan needed to be updated as soon as she was taken off in order to be accurate to show what care she required at this time. During an interview on 03/29/2024 at 12:50 p.m. the DON stated Resident #8's comprehensive care plan should have been updated right away to show she was no longer on isolation. She stated she did not remember when the resident was on isolation, but it was a while back. 2. Record review of Resident #88's face sheet, dated 03/29/2024, revealed she was admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation, heart failure unspecified, dependence on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 5 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 0657 supplemental oxygen, essential (primary) hypertension, and peripheral vascular disease. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #88's admission 5-day MDS assessment, dated 03/25/2024, revealed the resident's BIMS score was 15, which indicated cognition intact. Residents Affected - Few Record review of Resident #88's Texas OOHDNR (out of hospital do not resuscitate) form dated and completed 03/20/2024. Record review of Resident #88's physician order summary, dated 03/29/2024, revealed an order dated 03/20/2024 for DNR. Record review of Resident #88's care plan, with the last care plan with an initiated date of 03/19/2024 and target date of 06/25/2024 revealed Resident #88's full code status care planned and had not been revised to reflect current DNR code status. During an interview on 03/29/2024 at 12:02 p.m. the MDS coordinator stated code status was a DNR for Resident #88. The MDS coordinator further stated Resident #88's care plan had not been signed yet; it did say full code. The MDS coordinator stated the care plan should have been updated with the current code status. The MDS coordinator stated the care plan should have been updated as soon as possible once the OOHDNR was signed, and the SW was responsible for the code status care plan. The MDS coordinator stated the care plan was important to the staff to be able to look at the resident's needs. During an interview on 03/29/2024 at 12:41 p.m. the SW stated the team had their own sections of the care plan they would go in and update. The SW stated Resident #88 had discussed during the initial care plan she wanted to be a DNR, of which it was completed. The SW stated she just forgot to change Resident #88's care plan. During an interview on 03/29/2024 at 1:01 p.m. the DON stated importance was to have current information available to the staff. The DON further stated the SW updated the code status care plans. The DON further stated care plans were revised on review or immediately and there were different parts of the care plan that had different time frames. The DON stated the facility did not have a policy regarding Comprehensive Care Plans they followed the RAI manual. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in section 2-44, Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 6 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 - Few 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. Based on observation, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of one facility treatment cart observed. The facility failed to ensure the treatment care was secured when unattended. This deficient practice could affect residents and visitors and result in misappropriation of medications and injury. The finding was: Observation on 03/26/24 at 10:44 a.m. the facility treatment cart left unsecured During observation and an interview with LVN E on 03/26/2024 at 10:46 a.m., who then secured the cart, stated the cart was not supposed to be left unsecured Items in the cart included: antibiotic ointment, syringes and needles, and wound care cleanser and dressing supplies. She stated she did not know who left the care unattended and unsecured because nurses used the cart. Interview on 03/29/2024 at 11:45 a.m. with the DON, she stated nurses knew better to leave any of the medication carts or treatment carts, unlocked and unattended. She stated anyone could have obtained ointments and items from the cart, and she did not know why syringes and needles were even on the cart. She said it was a safety issue, and she would in-service staff on securing the cart immediately. Record review of the facility policy and procedure titled Medication Labeling and Storage revised date February 2023 reflected Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Record review of the facility policy and procedure titled Security of Medication Cart Revised April 2007 reflected Medication carts must be securely locked at all times when out of the nurse's view. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 7 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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. Residents Affected - Many The facility failed to ensure dietary staff facial hair was fully covered by beard restraints. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. The facility failed to ensure refrigerated food items were dated and properly sealed. The facility failed to ensure pantry food items when opened were dated and properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 03/26/2024 at 10:01 a.m. during initial tour (DD and dietician present) of the main kitchen the walk-in refrigerator revealed a bag of green onions open with in a zip lock which was open to air, not dated, tray rack with 2 trays of raw broccoli, 1 tray of apple slices, and 2 trays of sliced white cheese, all trays were covered with plastic wrap and not dated when prepared or to be discarded. The DD stated these items should have open dates, preparation dates along with discard dates as to when to be thrown out. Observation of the main kitchen pantry revealed 2 bags of pasta noodles wrapped in plastic wrap not dated, a zip lock bag of cheese crackers not dated, half bag of pine nuts on the top shelf of the pantry with a discard date of 03/10/2024, 25 pound bag of whole grain brown rice with less than a quarter of the bag left not sealed opened to air not dated, and a 50 pound bag of light brown sugar quarter of the bag remaining not sealed open to air not dated. The dietician stated the item past the discard date she figured had not been used or the staff would have noticed and thrown them out. The dietician further stated the times which were opened to air and not sealed should have been sealed due to it could allow for pest to get in them, however she had not noticed any pest. The DD stated all the items in the pantry when opened should be sealed with a zip lock bag, plastic wrap or placed in a bin with an open date and discard date. The dietician further stated by sealing the items would protect against food borne illnesses. Observation 03/26/2024 at 10:17 a.m. revealed [NAME] B enter the main kitchen pantry from the stove and meal preparation area with his beard restraint/guard under his chin leaving his approximately 1-inch chin hair exposed. During an interview on 03/26/2024 at 10:30 a.m. [NAME] B stated his beard guard will slide down his face. [NAME] B further stated his beard guard keeps the hair from his face from going into the food which could be bad for residents if he was sick and could make residents sick. [NAME] B stated by not wearing it properly could affect the safety of the food. Observation and interview 03/26/2024 at 11:20 a.m. DS A was observed in the satellite kitchen with the side of his beard past his jaw along his neck with 1 inch facial hair exposed preparing drinks and placing desserts on trays. DS A when asked about his facial hair restraint (beard guard) not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 8 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 covering the rest of his facial hair adjusted his beard restraint/beard guard however, due to hair located past his jaw line and on the side of his neck had difficulty covering it. DS A stated the reason for wearing a beard restraint was to keep hair from going into the food and kept the residents from getting sick. DS A stated the restraint prevented cross contamination of food and drinks. Observation and interview on 03/26/2024 at 11:38 p.m. DD was observed to also have facial hair growth beyond the jaw line. DD stated usually the kitchen staff are to maintain the beard or facial hair and adjusted his beard restraint/guard. Observation and interview on 03/28/2024 at 10:34 a.m. revealed in the main kitchen pantry a 50-pound bag of stone-ground whole wheat torn at the top open look to be about 3/4 of the bag remaining however, the executive chef stated she thought the bag had just been torn when placed on the shelf and was still full. The dietician stated the wheat should have been in a bin. Observation on 03/28/2024 at 3:16 p.m. revealed [NAME] C at the 3 compartments sink rinsing off a pan was called by another cook due to his having pasta in a strainer in the sink and cold water running over it. [NAME] C came over to the sink turned off the water and then began shaking the strainer, placed it back down in the sink, stuck his gloved hands into the strainer then began scooping up the pasta then releasing it back into the strainer with his hands without having washed his hands or changed his gloves. [NAME] C then took the strainer over to the stove began scooping the pasta out with a spoon placing in the pan on the stove then stirring it. During an interview on 03/28/2024 at 3:20 p.m. [NAME] C stated he should have washed his hands and changed gloves to prevent contamination. [NAME] C further stated he had received training regarding cross contamination. During an interview on 03/28/2024 at 3:25 p.m. the DD stated the cook should have washed his hands and changed his gloves, he then further stated the cook would need more education. During an interview on 03/29/2024 12:14 p.m. with the ADM stated when items are opened and stored items should be dated and sealed to air depending on the food. The ADM further stated being exposed to air could affect the quality of food can affect the palatability of it. The ADM stated according to their policy anytime producing food or handling food hair restraints should be worn and if in a food prep area. The ADM stated the purpose of hair/facial restraints was to prevent hair from coming in contact with food to prevent risk of cross contamination. Review of facility policy section, Production, Purchasing, Storage, subject Food and Supply Storage, date issued 05/95 and revised 04/2024, read Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and date unused portions and open packages. Dry Storage: Store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight fitting lids . Review of facility Hourly Team Member handbook, no date, read section 5.1 Personal Appearance and Handwashing, For all Associates: Facial hair must be kept neatly trimmed, For Associates working in food service accounts: Hair nets or hats should be worn as appropriate. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 9 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Level of Harm - Minimal harm or potential for actual harm Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 10 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 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 disease and infection for 2 of 4 residents (Resident #10 and #85) reviewed for infection control, in that: Residents Affected - Few 1. The facility failed to keep Resident #10's indwelling urinary catheter drainage bag from touching the floor, and CNA F placed it onto Resident #10's bed after it was on the floor when she performed catheter care for the resident. 2. The facility failed to keep Resident #85's indwelling urinary catheter bag from touching the floor and CNA G placed the bag which touched the floor onto the bed and then into the resident's lap when she transferred her from the bed to her wheelchair. These failures could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #10's electronic face sheet dated 03/28/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: cerebral infarction due to thrombosis (stroke caused by a blood clot that develops in the arteries supplying blood to the brain), hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body), diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #10's admission MDS assessment dated [DATE] reflected she had an indwelling catheter. She scored a 03/15 on her BIMS which signified she was severely cognitively impaired. Record review of Resident #10's comprehensive person-centered care plan (undated) reflected Focus, has an indwelling urinary catheter r/t neurogenic bladder and urinary retention. Observation on 03/28/2024 at 1:35 p.m. of CNA F and CNA H perform catheter care for Resident #10. CNA F picked the indwelling urinary catheter drainage bag which touched the floor and placed it onto Resident #10's bed. Interview on 03/28/2024 at 1:55 p.m. with CNA G revealed she noticed the resident's urinary drainage bag touched the floor and it was not in a carrier bag. She stated the issue was infection control. She stated they were trained not to have the indwelling catheter, tubing, or drainage bag touch the floor because of cross contamination. Interview on 03/28/2024 at 2:09 p.m. with CNA H revealed she worked at the facility for a year. She stated the catheter bag should have been in a holder. She stated cross contamination was why the drainage bag should not touch the floor. She stated they were trained to have the drainage bag in a holder. 2. Record review of Resident #85's electronic face sheet dated 03/28/2024 reflected she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 11 of 12 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 676303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mirador 5857 Timbergate Dr Corpus Christi, TX 78414 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 admitted to the facility on [DATE]. Her diagnoses included: traumatic subdural hemorrhage without loss of consciousness (bleed in the brain), hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body), diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). Record review revealed Resident #85 was a new admission and did not have an MDS assessment completed. Record review of Resident #85's baseline care plan dated 03/21/2024 reflected she had an indwelling urinary catheter. Observation on 03/28/2024 at 08:10 a.m. of CNA G transferring Resident #85 from her bed to her wheelchair revealed Resident #85's indwelling urinary catheter drainage bag was resting on the floor. CNA G picked the drainage bag up off the floor and set it on Resident #85's bed, and then moved it onto the resident's lap when she was placed into her chair. Interview on 03/28/2024 at 1:46 pm. with CNA G revealed the drainage bag was not supposed to touch the floor. We are trained to have it in the bag so it does not touch the floor. She stated she did not really think about it. She stated placing the bag from the floor to a clean surface could cause cross contamination and infection. Record review of the facility competency assessment titled Catheter Care, Urinary revised dated September 2014, reflected Infection Control: Use Standard precautions when managing or manipulating the catheter, tubing, or drainage bag. Record review of the facility policy and procedure titled Catheter Care, Urinary revised dated August 2022 reflected the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Record review of CDC presentation titled Indwelling Urinary Catheter Insertion and Maintenance undated reflected Maintain Unobstructed Urine Flow .Keep the urine bag off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676303 If continuation sheet Page 12 of 12