Inspection·January 31, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few get to the smoking area independently, can independently and safely light her smoking materials, cannot extinguish her smoking materials independently, and can dispose of ashes appropriately. The assessment noted Resident #16 would shake or have tremors while smoking as well as visible burn marks on her clothing/coat. It further noted, This resident requires a fire-resistant smoking apron while smoking. Record review of Resident #16's Safe Smoking assessment dated [DATE] revealed Resident #16 does not know where the designated smoking area is located, cannot get to the smoking area independently, cannot independently and safely light her smoking materials, cannot extinguish her smoking materials independently, and cannot dispose of ashes appropriately. The assessment noted Resident #16 had visible burn marks on her clothing/coat. It further noted, This resident is safe to smoke unsupervised at this time. During an interview on 01/30/23 at 12:10 PM the DON said he and the ADONs did Safe Smoking Assessments. When asked why Resident #16's Safe Smoking Assessment seemed to contradict her care plan, the DON stated, That is wrong, let me look at that and see who did that last assessment. During an interview on 01/31/23 at 9:30 AM Resident #16 stated she is not allowed to go outside alone to smoke. During an interview on 01/31/23 at 09:38 AM MDS RN said she is responsible for residents' care plans. When asked for a possible negative outcome of a care plan not aligning with the most current assessment of a resident, she replied, Well, I mean there could be missed opportunities to provide care. During an interview on 01/31/23 at 9:50 AM the ADM stated the facility performed Safe Smoking Assessments on all smokers quarterly. When asked what direct supervision meant as stated on the assessment the ADM answered, That a staff member is out there with them the whole time they are smoking. She said Resident #16 is not allowed to smoke alone. When asked for a possible negative outcome of Resident #16's care plan not aligning with her Safe Smoking Assessment, the ADM replied, The staff do not know what their duty is in the care for that resident. During an interview on 01/31/23 at 10:05 AM the DON stated he and the ADONs did Safe Smoking Assessments quarterly. He said Resident #16 was not allowed to smoke independently. When asked why Resident #16's care plan stated she could smoke independently, the DON answered, I fixed that yesterday . That information was from 2016 and had not been updated. He said a negative outcome from a resident's care plan not aligning with the most recent Safe Smoking Assessment was, Someone who doesn't know the resident might let them smoke alone. Record review of the facility's undated policy titled, Comprehensive Care Planning revealed, in part, The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives.The resident's care plan will be .revised based on changing goals .and needs of the resident and in response to current interventions. Record review of the facility's policy titled, Smoking Policy and dated 11/01/17 revealed, in part, .3. If the facility identifies that the resident needs assistance/supervision and/or additional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 2 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 protective devices for smoking, the facility includes this information in the resident's care plan, and reviews and revises the plan periodically as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 3 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 interviews and record reviews the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 3 of 17 residents (Resident #6, Resident #16, and Resident #20) reviewed for care plan timing. The comprehensive care plan for Resident #6 was not developed within 7 days after the completion of the comprehensive assessment. The comprehensive care plan for Resident #16 was not developed within 7 days after the completion of the comprehensive assessment. The comprehensive care plan for Resident #20 was not developed within 7 days after the completion of the comprehensive assessment. These failures could place residents at risk of receiving care that is not person-centered and/or is inadequate to meet the needs identified during the comprehensive assessment. Findings Include: 1. Record review of Resident #6's face sheet, dated 01/31/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia, major depressive disorder, heart failure, Crohn's disease, and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #6's annual MDS dated [DATE] revealed a BIMS of 12 which indicated moderate cognitive impairment. Record review of Resident #6's MDS tab in the EHR revealed the following: A Quarterly MDS dated [DATE] and noted to be in progress An Annual MDS dated [DATE] A Quarterly MDS dated [DATE] A Quarterly MDS dated [DATE] A Quarterly MDS dated [DATE] An admission MDS dated [DATE] Record review of Resident #6's care plan tab in the EHR revealed the following: A care plan with a start date of 11/09/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 4 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 A care plan with a start date of 09/08/22 Level of Harm - Minimal harm or potential for actual harm A care plan with a start date of 06/08/22 A care plan with a start date of 05/20/22 Residents Affected - Few A care plan with a start date of 02/24/22 2. Record review of Resident #16's face sheet, dated 01/31/23 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, multiple sclerosis, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), history of falling, heart failure, schizoaffective disorder bipolar type (mental disorder in which a person experience a combination of symptoms of schizophrenia and mood disorder), and type 2 diabetes. Record review of Resident #16's Quarterly MDS dated [DATE] revealed a BIMS of 14 which indicated intact cognition. Record review of Resident #16's MDS tab in the EHR revealed the following: An Annual MDS dated [DATE] and noted to be in progress A Quarterly/Medicare-5 Day MDS dated [DATE] A Quarterly MDS dated [DATE] A Quarterly MDS dated [DATE] Record review of Resident #16's care plan tab in the EHR revealed the following: A care plan with a start date of 12/27/22 A care plan with a start date of 09/30/22 A care plan with a start date of 07/05/22 A care plan with a start date of 04/07/22 A care plan with a start date of 03/28/22 3. Record review of Resident #20's face sheet, dated 01/31/23 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia, anxiety disorder, type 2 diabetes, brief psychotic disorder, major depressive disorder, and heart disease. Record review of Resident #20's Quarterly MDS dated [DATE] revealed a BIMS of 13 which indicated intact cognition. Record review of Resident #20's MDS tab in the EHR revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 5 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 A Quarterly MDS dated [DATE] and noted to be in progress Level of Harm - Minimal harm or potential for actual harm A Quarterly MDS dated [DATE] An Annual MDS dated [DATE] Residents Affected - Few A Quarterly MDS dated [DATE] A Quarterly MDS dated [DATE] A Quarterly MDS dated [DATE] An Annual MDS dated [DATE] A Quarterly MDS dated [DATE] A Quarterly MDS dated [DATE] Record review of Resident #20's care plan tab in the EHR revealed the following: A care plan with a start date of 01/18/23 A care plan with a start date of 10/20/22 A care plan with a start date of 09/23/22 A care plan with a start date of 06/30/22 A care plan with a start date of 05/10/22 During an interview on 01/31/23 at 9:38 AM the MDS RN stated it is her responsibility to ensure care plans are timed correctly with MDS assessments. She said, A care plan should be done 14 days after MDS. When asked why this timing was important, she replied, Because MDS runs the care plan. Basically, that is where you get all of our triggers, you need the MDS completed so you know how to care plan that resident. The MDS RN stated she follows the RAI manual as well as facility policies when she is performing care plans and MDS assessments. When asked why the care plans for Residents #6, #16, and #20 were not scheduled according to the policy mentioned she answered, It is an accident. It's a work in progress. She said if the care plan is not updated according to the most recent assessments there could be missed opportunities to provide care according to the resident's needs. During an interview on 01/31/23 at 9:50 AM the ADM said care plans should be done within 7 days of the MDS. When asked for a possible negative outcome of this timing not being adhered to, she replied, We might not be moving in the right direction for the care that is needed, and we could be have a negative effect on the care instead of a positive effect. During an interview on 01/31/23 at 10:05 AM the DON said a possible negative outcome of a care plan not being updated to reflect the most recent MDS was you're not catching everything that needs to be caught and care planned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 6 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's undated policy titled, Comprehensive Care Planning revealed, in part, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Care planning drives the type of care and services that a resident receives.When developing the comprehensive are plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.A comprehensive care plan will be-Developed within 7 days after completion of the comprehensive assessment.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Event ID: Facility ID: 676341 If continuation sheet Page 7 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 24 residents (Resident #17) reviewed for respiratory care. Residents Affected - Few The facility failed to obtain orders for Resident #17's oxygen therapy upon admission resulting in him receiving the incorrect dose. This failure could affect all resident on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Resident #17 Record review of Resident #17's face sheet revealed a [AGE] year-old male resident admitted to the facility originally on 1-23-2023 with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make if difficult to breath), pulmonary candidiasis (a rare condition that usually occurs in immunosuppressed patient with the presence of Candida in the respiratory tract), cardiomyopathy (an acquired or hereditary disease of the heart muscle), malnutrition (lack of proper nutrition), and hypertension (a condition in which the force of the blood against the artery wall is too high). Record review revealed Resident #17''s clinical record revealed he was admitted [DATE] and was not due for a full MDS evaluation at the time of this survey. Record review of Resident #17's Physician Orders printed 1-31-2023 with active orders as of 1-23-2023 revealed no orders for oxygen therapy. Record review of Resident #17's clinical record revealed a care plan dated 1-24-2023 for the following: Problem: The resident has COPD Intervention: Give oxygen therapy as ordered by the physician. Record review of Resident #17's Weight and Vitals printed 1-31-2023 revealed the following: 1-31-2023 at 08:55 AM: O2 sat of 97% with nasal cannula 1-30-2023 at 08:12 PM: O2 sat of 94% on room air 1-30-2023 at 07:05 AM: O2 sat of 93% with nasal cannula 1-29-2023 at 08:55 AM: O2 sat of 93% with nasal cannula (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 8 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 1-29-2023 at 12:14 AM: O2 sat of 98% with nasal cannula Level of Harm - Minimal harm or potential for actual harm 1-28-2023 at 06:07 AM: O2 sat of 97% with nasal cannula 1-27-2023 at 09:18 PM: O2 sat of 94% with nasal cannula Residents Affected - Few 1-26-2023 at 08:01 AM: O2 sat of 89% with nasal cannula 1-25-2023 at 09:33 PM: O2 sat of 92% with nasal cannula 1-25-2023 at 08:21 AM: O2 sat of 89% with nasal cannula 1-24-2023 at 08:40 PM: O2 sat of 94% with nasal cannula During an observation on 01-29-23 at 10:12 AM Resident #17 was in his room sitting in his wheelchair watching TV wearing his O2 via nasal cannula. His oxygen was noted to be set at 3L/min. During an interview on 01-31-23 at 09:36 AM with DON the Compliance Nurse, when questioned if Resident #17 had orders for Oxygen therapy the DON reviewed the residents' orders and reported that Resident #17 was a readmission, and that Resident #17 oxygen therapy was discontinued on Resident #17 last discharge 7-3-2022 and was not renewed when Resident #17 was readmitted on [DATE]. The DON reported that he would call the provider (Nurse Practitioner) and verify that she still wanted Resident #17 on oxygen. The compliance nurse reported that she would check Resident #17 and verify what dose of oxygen Resident #17 was on. The DON called the provider with this surveyor present, and the DON reported that Resident #17 was on O2 at 3 liters that was not renewed when Resident #17 was admitted on [DATE] and that Resident #17 was admitted with COPD. The provider told the DON that since the resident had COPD, she would order his O2 therapy but only at 1-2liters/min. The compliance nurse reentered the DON's office and reported that she verified that Resident #17 was on 3liters per minute. The DON instructed the compliance nurse that the provider agreed with re-ordering the O2 but only and 1-2 liters per minute due to his COPD. The compliance nurse reported that she would make sure the resident was on that dose and left the room. When questioned what could be the consequences of not ordering medications such as oxygen therapy the DON stated, Literally what we just had happen. The DON reported that the facility could end up not administering a medication correctly. The compliance nurse reported that they were discussing in morning reported this AM that they needed to review all new admission orders and were planning on doing an in-service to address this very issue. During an interview on 01-31-23 at 10:22 AM the DON reported that he did not think the facility had a policy that addressed the implementation of orders especially at admission and ensuring that they were correct but that he would review the policy and procedure manual again to see. Record Review of the facility provided policy titled Physician's Orders dated Medical Records Manual dated 2015 revealed the following: Purpose-To monitor and ensure the accuracy and completeness of medication orders, treatment orders, and ADL orders for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 9 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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. Based on the observations, interviews, and record reviews the facility failed to store food in accordance with professional standards for food service safety to prevent food borne illness, and kitchen pest contamination in the facility's only kitchen reviewed for dietary services in that: Dry storage area: In the dry storage shelves, there was an expired hotdog bread. A pink colored powder substance was scattered on top of several cans of chicken noodle soups. Jell-O bags were located above the cans of the chicken noodle soups. A white powdery substance was scattered on top of several cans of cream of coconut. Above the cream of coconut cans there were jars of salt. In the kitchen area, there was a bag of bread with an expired date, and a bag of tortillas with an expired date also. These failures placed residents who ate the food served by the kitchen in food-borne illness and potential for a kitchen pest contamination. Findings include: In an observation of the walk-in pantry on 01/29/2023 at 09:20 AM the following was observed: 1. Dry storage area: 1 unopened bag of hotdog bread with a use by date of 01/29/2023 2. Dry storage area: Cans of chicken noodle soup have pink colored powder scattered on top of the cans of food. 3. Dry storage area: Cans of cream of coconut have white colored powder scattered on top of the cans of foods In an observation of the kitchen on 01/29/2023 at 09:40 AM the following was observed: 1. A bag of bread with a use by date of 01/27/2023. 2. A bag of opened flour tortillas with a date of 12/31/2022 and use by 7 days. In an interview on 01/29/2023 at 10:10 AM, the dietary aide stated cans with powdered substance on top of them should not have any powder. Dietary aide said pantry area will be clean, should be always clean, and will make sure there are no open bags of Jell-O or salt or any other open bags. Pantry area will be clean and organized. Dietary aide stated bread and tortillas will be thrown away and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 10 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 should have been thrown away by the expiration date. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/30/2023 at 09:23 AM, dietary supervisor stated all the kitchen staff are responsible in throwing out the expired food. All kitchen staff are responsible in keeping the pantry area clean. Staff are trained in making sure expired food is thrown out and keeping the pantry clean. Dietary supervisor stated the negative outcome of having Jell-O spilled in pantry is that it can attract bugs or ants. Dietary supervisor stated the negative outcomes of not throwing out expired food is that food can be served when should not be eatable. Residents Affected - Many In an interview on 01/30/2023 at 09:40 AM, the dietary aid stated all kitchen staff are responsible in throwing out expired food and making sure the pantry area is clean. The negative outcomes of having Jell-O spilled in the pantry is that it can attract bugs. The negative outcome of not throwing out expired food is that it can get people sick. In an interview on 01/31/2023 at 12:45 PM, the administrator stated the dietary manager is responsible in making sure expired food is thrown out and pantry area is maintained clean. The negative consequences of having powder scattered on top of cans of food is that it can get mixed with the food when the cans are being opened or can attract bugs. The negative consequence of having expired food is that if a person eats expired food, can make the person sick. Record Review of the facility's Food Storage Policy dated 2012: #4 states, Dry bulk foods (e.g. flour, sugars) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are clean regularly. #6 states, When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. Any product with a stamped expiration date will be discarded once that date passes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 11 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 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 diseases and infections for 1 (CNA A) of 7 staff observed for resident care. Residents Affected - Few -CNA A failed to wash her hands while providing incontinent care for Resident #31 This deficient practice has the potential to affect residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation on 01-30-23 at 11:43 AM CNA A performed incontinent care on Resident #31. CNA A washed her hands prior to starting the incontinent care. placed gloves, cleaned Resident #31's peri area with five different wipes, changed her gloves, cleaned Resident #31's rectal area 3 times with the first wipe noted to have a small brown stain, CNA A changed her gloves, CNA A then placed the new brief under Resident #31, then CNA A place cream on Resident #31's rectal areas, CNA A changed her gloves, and finished placing the new brief. CNA A finished dressing Resident #31 and placed Resident #31 in a position of comfort, then CNA A removed her gloves and washed her hands. CNA A did not wash her hands or use hand sanitizer at any time while performing the incontinent care. During an interview on 01-30-23 at 11:59 AM CNA A reported that if her gloves are visibly soiled with BM then she will wash her hands. If they are not, then she will use hand sanitizer. CNA A reported that her gloves were not visibly soiled so she did not need to wash her hands, that if Resident #31 had a big BM or had diarrhea then she would have washed her hands or used hand sanitizer. CNA A reported that if your gloves are soiled or the resident has a big BM or diarrhea then residents could get an infection. During an interview on 01-30-23 at 02:27 PM the DON reported that staff are expected to wash their hands when they start care and when they finish care and if they notice that their gloves are soiled. They are to use hand sanitation with each glove change. That with incontinent care they are to wash their hands when gloves are visibly soiled. That the time that is takes to wash hands will take staff away from the resident care and put residents at risk when staff are away to perform the handwashing. That staff can use hand sanitation with ABHR with each glove change as long at the gloves are not soiled. The DON reported that sanitation is performed to prevent bacteria so when a staff member puts on new gloves, they do not have bacteria on their hands and their hands are clean when they put on the new gloves. The DON reported that if hand hygiene/sanitation is not performed then a resident can be placed at risk for cross contamination. The DON verified that training is completed at least quarterly for Hand Hygiene and that all direct care staff are trained. He verified that he provided the last training, and that CNA A was trained on hand hygiene. Record review of the facility provided policy titled Perineal Care dated 5-11-2022 revealed the following: Important Points (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 12 of 13 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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 -Always perform hand hygiene before and after glove use. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 13 of 13