Inspection·March 26, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #24's progress notes dated 03/24/24 at 07:45 PM and reflecting 02/23/24 to 03/25/24 revealed no progress notes dated 03/24/24. During an observation on 03/24/24 at 11:30 AM Resident #24 was seated at a table in the dining hall with milk spilled on the floor in front of her and a styrofoam cup on the table. A walker was next to her and had a black bag attached to the top horizontal bar. She stood from the table and walked with her walker to the front of the dining room where drinks were sitting in styrofoam cups near the drink dispenser. Resident #24 picked up a styrofoam cup of what appeared to be pink lemonade and placed it in the black bag hanging from her walker. She proceeded to walk back to her table and take the cup out of the bag and sat it on the table and sat down in the same chair. During an observation on 03/24/24 at 11:31 AM CNA G noted spots of milk on the floor of the dining hall toward the front of the dining hall. She went into the kitchen and returned with what appeared to be a trash bag and paper towels and began to wipe up the spots of milk with the paper towels which she threw into the plastic trash bag. CNA G followed the trail of milk to where Resident #24 was seated at the table with both styrofoam cups on the table in front of her. CNA G wiped up the large spill of milk near Resident #24's feet and walker and seemed to notice the milk was coming from the bag attached to Resident #24's walker. CNA G looked into the bag and said something to another staff member standing nearby as she (CNA G) removed the bag from the walker by loosening velcro straps and placed the black bag in the trash bag. Resident #24 sat in her chair at the table and did not say anything to CNA G. CNA G then proceeded to twist the top of the trash bag closed and walk toward the front of the dining room carrying the trash bag. During an observation and interview on 03/25/24 Resident #24 was seated at a table in the dining room. Her walker was beside her chair and did not have a bag hanging from the horizontal bar. When asked what happened to the bag she used to have on her walker, Resident #24 stated, They took it. When asked if she would like another bag she said, Yes. During an observation on 03/26/24 Resident #24's walker was in her room next to her bed. It did not have a bag hanging from the horizontal bar. During an interview on 03/26/24 at 01:50 PM CNA G stated she was working in the dining room on 03/24/24 and noticed milk coming out of the bag on Resident #24's walker. She stated she saw milk in the bag and told Resident #24 she was going to throw the bag away because of the milk in it. CNA G stated Resident #24 said that was okay. CNA G said she would not throw out property of a resident even if it looked gross to her because it was their property. During an interview on 03/26/24 at 01:52 PM DON stated if a staff member found milk in the bag of a resident the staff member should clean the bag. She stated it was never okay to throw away a resident's possession without permission. She said a possible negative outcome to throwing away a resident's possession without permission was, It would be a loss of their property. She stated if there was a situation where the possession might cause harm to the resident and the resident was not able to understand why it needed to be thrown away, they would involve family and/or have a care plan. Record review of facility policy titled Resident Rights and dated 11/28/16 revealed the following: . Respect and Dignity - The resident has the right to be treated with respect and dignity, including: . 2. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 2 of 20 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 03/26/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 the resident had the right to the reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident and or other residents for 5 (Resident #2, Resident #8, Resident #18, Resident #29, and Resident #46) of 18 residents reviewed for reasonable accommodation of resident needs and preferences. Residents Affected - Some The facility failed to provide residents with silverware and dishes for 2 weeks, instead providing plasticware and styrofoam. This failure could lead to residents having difficulty eating and thereby becoming frustrated and/or not receiving necessary nutrition. Findings Included: 1. Record review of Resident #2's admission record dated 03/26/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with a more recent admission date of 10/25/21. Resident #2 had diagnoses that included, but were not limited to, hemiplegia and hemiparesis (partial paralysis) affecting right dominant side, muscle weakness, pain in left shoulder, protein-calorie malnutrition, vitamin deficiency, muscle wasting and atrophy, and muscle spasm. Record review of Resident #2's quarterly MDS completed on 02/06/24 revealed a BIMS of 15 which indicated intact cognition. Section GG of the MDS revealed Resident #2 needed setup and clean up assistance with eating. Section I of the MDS revealed an active diagnosis of Malnutrition (protein or calorie) or at risk for malnutrition. Record review of Resident #2's care plan completed on 01/01/24 revealed Resident #2 had vitamin B-12 deficiency anemia and staff were to encourage him to eat foods high in iron and vitamin C. The care plan further revealed Resident #2 had partial paralysis and was at risk for malnutrition. Resident #2 required setup help with eating. Interventions for this focus area included staff providing Resident #2 with finger foods when he had difficulty using utensils. Resident #2 was able to hold his cup, feed himself, and eat finger foods independently. Record review of Resident #2's dietary order dated 04/05/23 revealed Large Portions diet Regular texture, Regular consistency. During an observation and interview on 03/24/24 at 09:40 AM Resident #2 was seated in his motorized w/c in his room. He stated residents were still having to eat out of styrofoam containers. During an observation and interview on 03/25/24 at 10:30 AM Resident #2 was in his motorized w/c in the private dining area. He stated residents had to use plasticware and styrofoam dishes due to the kitchen not having any hot water to wash dishes. He said this had been going on for 2-3 weeks with a few days in between where the hot water was working. Resident #2 stated on 03/24/24 at lunch his plastic fork broke when he was attempting to cut his chicken fried steak. 2. Record review of Resident #8's admission record dated 03/26/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with a more recent admission date of 04/01/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 3 of 20 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 03/26/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #8 had diagnoses that included but were not limited to vitamin B deficiency, vitamin D deficiency, protein-calorie malnutrition, muscle weakness, lack of coordination, and muscle wasting and atrophy. Record review of Resident #8's quarterly MDS completed on 03/25/24 revealed a BIMS of 12 which indicated moderate cognitive impairment. Section GG indicated Resident #8 needed setup and clean up assistance with eating. Section I noted Resident #8 had a diagnosis of Malnutrition (protein or calorie) or at risk for malnutrition. Record review of Resident #8's care plan completed on 12/28/23 revealed Resident #8 was at risk for malnutrition. Resident #8 required setup assistance to eat and had a diet order for mechanical ground meat, regular consistency. Record review of Resident #8's dietary order dated 08/22/23 revealed the following order, Regular diet, Regular with Mechanical Ground Meat texture, Regular consistency, needs meat cut up. During an observation on 03/24/24 at 09:50 AM Resident #8 was sitting on the side of her bed eating breakfast out of a styrofoam tray on her bedside table. During an observation and interview on 03/25/24 at 10:30 AM Resident #8 was seated in her w/c in the private dining area of the facility for a Resident Council meeting. She nodded her head in agreement when Resident #2 and Resident #18 said that using plasticware and styrofoam dishes made eating harder. During an observation and interview on 03/26/24 at 08:27 AM Resident #8 was seated on the side of her bed eating breakfast from a styrofoam tray on her bedside table. She stated it was hard to eat her food with plasticware. 3. Record review of Resident #18's admission record dated 03/24/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with a more recent admission date of 11/21/23. Resident #18's admission record revealed diagnoses that included, but were not limited to, moderate protein-calorie malnutrition, vitamin D deficiency, muscle wasting and atrophy, muscle weakness, and lack of coordination. Record review of Resident #18's annual MDS completed on 02/29/24 revealed a BIMS of 7 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #18 needed setup and clean up assistance with eating. Section I noted Resident #18 had a diagnosis of Malnutrition (protein or calorie) or at risk for malnutrition. Record review of Resident #18's care plan completed on 02/29/24 revealed Resident #18 was at risk for malnutrition and had potential for nutritional problems. Resident #18 had a diet order for regular diet, regular texture, regular consistency. Record review of Resident #18's dietary order dated 11/21/23 revealed Regular diet Regular texture, Regular consistency. During an observation on 03/24/24 at 12:09 PM Resident #18 was seated in the dining room. She was served her lunch in a square styrofoam, lidded container. The lunch was chicken fried steak, fried okra, mashed potatoes, gravy, and a roll. Next to the square container she was served a small (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 4 of 20 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 03/26/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some styrofoam bowl with a piece of yellow cake and a styrofoam cup with what appeared to be pink lemonade. Resident #18 appeared to have difficulty cutting the chicken fried steak to take a bite. During an observation and interview on 03/25/24 at 10:30 AM Resident #18 was in her w/c in the private dining area for a Resident Council meeting. She stated on 03/24/24 it was difficult to cut her chicken fried steak with the plasticware provided. When Resident #2 said his fork broke in his attempts to cut his chicken fried steak Resident #18 said her fork also broke when she was attempting to cut her chicken fried steak. When another Resident #46 mentioned that the styrofoam cups were hard to drink out of due to being pliable and squeezing the liquid out of the top of the cup, Resident #18 nodded her head in agreement. 4. Record review of Resident #29's admission record dated 03/26/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart disease and chronic pain syndrome. Record review of Resident #29's quarterly MDS completed on 03/07/24 revealed a BIMS of 15 which indicated intact cognition. Section GG of the MDS revealed Resident #29 needed setup and clean up assistance with eating. Record review of Resident #29 care plan completed on 12/28/23 revealed Resident #29 was at potential risk for malnutrition and had a dietary order for Regular diet, regular texture, regular consistency. Record review of Resident #29's dietary order dated 01/03/20 revealed, Regular diet Regular consistency, 1 salad 4x a week with any meal. During an observation and interview on 03/24/24 at 10:58 AM Resident #29 was seated in her recliner in her room. She stated the kitchen has hot water for a day or two and then it goes off again. Resident #29 stated she knew this because staff told her and because she would be served her meals in styrofoam containers when the hot water was not working. During an observation and interview on 03/24/24 at 08:46 AM Resident #29 was seated in her recliner her bedside table in position in front of her. She had two small styrofoam bowls and a styrofoam cup on the bedside table along with a plastic spoon and a plastic fork. She stated she had to use plasticware and styrofoam dishes because they (facility staff) claim the dishwasher has not been functioning right. During an observation and interview on 03/25/24 at 10:30 AM Resident #29 was in her w/c in the private dining area for a Resident Council meeting. Upon hearing another resident state his fork broke trying to cut his chicken fried steak on 03/24/24 at lunch, Resident #29 said her plastic fork also broke while she was attempting to cut her chicken fried steak. She said it was almost impossible to cut it (the chicken fried steak). 5. Record review of Resident #46's admission record dated 03/24/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with a more recent admission date of 08/03/23. Resident #46 had diagnoses that included, but were not limited to, severe protein-calorie malnutrition and vitamin D deficiency. Record review of Resident #46's quarterly MDS completed on 12/24/23 revealed a BIMS of 15 which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 5 of 20 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 03/26/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated intact cognition. Section GG of the MDS revealed Resident #46 needed setup and clean up assistance with eating. Section I of the MDS revealed a diagnosis of Malnutrition (protein or calorie) or at risk for malnutrition. Record review of Resident #46's care plan completed on 02/20/24 revealed Resident #46 had potential risk for malnutrition and required supervision when eating. Resident #46 had a dietary order for Regular diet, Regular texture, Regular consistency. Record review of Resident #46's dietary order dated 08/03/23 revealed Regular diet Regular texture, Regular consistency. During an observation and interview on 03/24/24 at 12:15 PM Resident #46 was seated at a table in the dining room. She was served her lunch in a square styrofoam, lidded container along with a small styrofoam bowl which contained a piece of yellow cake and a styrofoam cup of what appeared to be tea. Resident #46's lunch included a chicken fried steak which she stated was very difficult to cut up with a plastic knife and fork. Resident #46 was observed struggling to cut her chicken fried steak. During an observation on 03/24/24 at 12:51 PM surveyors received a test tray from the kitchen. The tray contained plasticware and a chicken fried steak, fried okra, mashed potatoes, gravy, and a roll on a styrofoam plate situated underneath a brown plastic plate cover. There was a styrofoam bowl which contained a piece of vanilla cake. Two attempts were made by this surveyor to use the plastic knife and plastic fork provided to cut the chicken fried steak both attempts failed. This surveyor resorted to pulling the chicken fried steak apart using both of my hands. During an observation and interview on 03/25/24 at 10:30 AM Resident #46 was seated in her w/c around the table in the private dining room. She stated the styrofoam cups residents were being given due to no hot water in the kitchen were hard to handle. She picked up a styrofoam cup of what appeared to be coffee with cream in front of her and demonstrated that it was easy to squeeze the sides of the cup and cause the liquid inside to get close to spilling over the top of the cup. She stated it was difficult to cut her food with the plasticware in the styrofoam boxes. During an observation in the kitchen on 03/25/24 at 10:38 AM 3 large pots were observed with water in them on the stove to boil and use to sanitize the dishes used for cooking breakfast. Kitchen staff were observed lifting the pots of boiling water from the stove and dumping them into the sink. The pots were approximately 2 feet tall and 1.5 feet in diameter. During an interview on 03/26/24 at 08:55 AM DM stated the kitchen had been without hot water going on two weeks. She said her staff had been boiling water to clean the dishes they used to prepare the meals. During an interview on 03/26/24 at 01:38 PM RM stated the hot water stopped working in the kitchen on 03/14/24. The wrong part came to the facility on [DATE]. The correct part came on 03/25/24 but the hot water heater did not work until they factory reset the water heater on 03/26/24. During an observation and interview on 03/26/24 at 01:50 PM DM stated a possible negative outcome of no hot water in the kitchen for two weeks was, We all have back aches from carrying large pots of boiling water to wash dishes. During an interview on 03/26/24 at 01:52 PM DON stated residents had been eating with plasticware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 6 of 20 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 03/26/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and styrofoam dishes for quite a while, at least 3 weeks. She stated, It has been on and off for, I think, 3 weeks. DON could not think of a negative outcome for residents having to eat with plasticware. Record review of facility policy titled Resident Rights and dated 11/28/16 revealed the following: . Respect and Dignity - The resident has a right to be treated with respect and dignity, including: . 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 revealed in part: . Setup or clean-up assistance: setup or clean up assistance was defined as the helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity, but not during the activity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 7 of 20 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 03/26/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in the resident's physical, mental, psychosocial status for 1 (Resident #24) of 18 residents reviewed for notification. The facility failed to ensure Resident #24's resident representative was immediately notified when the resident had a change in condition that required she be transported via ambulance to the hospital. This failure could result in residents not having the comfort and company of their families during traumatic times. Findings Included: Record review of Resident #24's admission record dated 03/24/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with a more recent admission date of 09/18/23. Resident #24 had diagnoses that included, but were not limited to, dementia, type 2 diabetes (an autoimmune disease that originates when cells that make insulin are destroyed by the immune system), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), generalized anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). The admission record further revealed Resident #24's family member was her emergency contact and primary caregiver. Resident #24 was noted as DNR. Record review of Resident #24's quarterly MDS completed on 01/23/24 revealed a BIMS of 3 which indicated severely impaired cognition. Record review of Resident #24's care plan completed on 02/26/24 revealed Resident #24 received an antiplatelet medication and was to be monitored for complications of anticoagulant medication which included blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools. Record review of Resident #24's progress note dated 09/13/23 and written by LVN F revealed Resident #24 had a Large amount of red blood noted in stool, low blood pressure, and pale color and was therefore transferred to a hospital. The note contained what appeared to be a form with blanks to place check marks in to indicate who was notified of the emergency transfer. There was an unchecked blank next to Resident and Resident Representative. The date section of the form was blank. Record review of Resident #24's hospital Discharge summary dated [DATE] with an admission date of 09/13/23 and a discharge date of 09/18/24 revealed Resident #24 had black stools for several days and began having vomiting with coffee ground emesis (an indication of blood in the vomit) prior to her admission to the hospital. Resident #24 had to be intubated (hollow plastic breathing tube inserted into windpipe) and placed in surgery for an intestinal ulcer that was being fed by two arteries and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 8 of 20 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 03/26/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few causing internal bleeding. These arteries required embolization (a medical technique that involves blocking the flow of blood in a particular blood vessel by putting material into the blood). During an interview on 03/24/24 at 06:46 PM Resident #24's emergency contact/family member stated Resident #24 was sent from the facility via ambulance to the local hospital and from there was transferred to a hospital in a larger town one hour away. She said she was not notified of Resident #24 leaving the facility until Resident #24 arrived at the second hospital in the larger town. She stated, She [Resident #24] was having internal bleeding and they sent (her) to [Name of town in which facility is located] hospital . Then rushed to [Name of larger town 1 hour away] where she had to have lifesaving surgery. They (facility) didn't call me til she was in [Name of larger town 1 hour away]. During an interview on 03/26/24 at 10:24 AM LVN F stated nurses were responsible for notifying family members if a resident had a change of condition or was transferred to the hospital. She stated, We are, as nurses, to immediately let them know if there are changes. She stated the contact information for the resident's family and emergency contacts was located on their profile in the EHR. LVN F stated the notification, Should be in a progress note or sometimes if we have an SBAR it will say any other comments and then say who was notified and when. LVN F stated the progress notes would also indicate who was notified and when. She stated she thought it was another nurse who would have notified Resident #24's family of her transfer to hospital. She said she could not remember who it would have been because, That was several months ago. During an interview and record review on 03/26/24 at 11:39 AM DON revealed a form titled eTransfer Form V 5. Record review of the form with DON revealed NP and family were notified on 09/13/24 but not what time they were notified. DON stated the form used to auto populate but it does not do that anymore. She stated she would look through Resident #24's record for a time of notification. During an interview on 03/26/24 at 11:47 AM DON stated she could not find any documentation of the time of notification of Resident #24's family member on 09/13/23. During an interview on 03/26/24 at 01:52 PM DON stated nurses were responsible for notifying family members of resident change of condition or transfer to hospital. She stated the notification was done via telephone and if the resident was being sent out to the hospital it should have been documented in progress notes, SBAR, and eTransfer. She stated a possible negative outcome of not immediately notifying family of a resident's transfer to hospital was, They might not be able to be there on time. During an interview on 03/26/24 at 02:00 PM ADM stated a possible negative outcome of not notifying a resident's family member immediately regarding transfer to the hospital was the family would be very upset, family needs to know where loved one is immediately. Record review of facility policy titled Notifying the Physician of Change in Status and dated 03/11/13 revealed the following: . The nurse will document the time of the call to the physician in the clinical record. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative . Record review of a facility policy titled Resident Rights and dated 11/28/16 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 9 of 20 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 03/26/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete . 14. Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is-a. An accident involving the resident which results in injury and has the potential for requiring physician intervention; b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) . 10. Notification of changes. A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives(s). Event ID: Facility ID: 676341 If continuation sheet Page 10 of 20 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 03/26/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for one of eighteen residents (Resident #6) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #6's MDS accurately reflected the resident's hospice status. This failure could place residents at risk of not having their needs identified and not receiving necessary care. Findings include: Record review of Resident #6's admission record, dated 10/19/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with orders to admit the facility for under the care of Hospice. Resident #6 had diagnoses which included, but were not limited to, Essential Hypertension (High Blood Pressure), Major Depressive Disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), Epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), Anxiety Disorder (a group of mental illnesses that cause constant fear and worry. Characterized by sudden feeling of worry, fear, and restlessness), Type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar), History of Transient Ischemic Attacks (brief stroke-like attack wherein symptoms resolve within 24 hours), Cerebral Infarction (blood supply to part of the brain is blocked or reduced. Prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes), Chronic Pain Syndrome (Pain that lasts for longer than 3 months) and Cirrhosis of the Liver (a degenerative disease resulting in scarring and liver failure). Record review of Resident #6's quarterly MDS, completed on 02/29/24, reflected a BIMS of 06, which indicated severely impaired cognition. Section O of the MDS reflected Resident #6 was not receiving Hospice classification on admission or while a resident. Record review of Resident #6's care plan, with a completion date of 02/27/24, reflected a focus area of the resident had a terminal prognosis and/or was receiving hospice services Date Initiated: 10/20/2023 and revised on 11/19/23. Interventions listed were to; observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. This intervention was initiated on 10/20/23 and revised on 11/19/23 and documented if receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Date Initiated: 10/20/2023 and revised on 11/19/23. During an interview on 03/25/24 at 2:31 PM, MDS LVN stated she followed the RAI as her policy for completing MDS Assessments She stated, I missed putting him on Hospice from his admission. When asked what a negative outcome from this could potentially be, she stated, He may not have gotten on Hospice. During an interview on 03/26/24 at 1:36 PM, the DON stated she was not sure what a negative outcome of the MDS being incorrect and not showing a resident as Hospice would be. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 11 of 20 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 03/26/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 03/26/24 at 1:39 PM, the Administrator stated, the MDS being incorrect and not showing the resident's hospice status was a monetary situation with billing. Record review of the Long-Term Care Facility RAI Manual version 1.18.11 reflected the following: . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods . Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs . Steps for Assessment 1. Review the resident's medical record to determine whether the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column . Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days. Event ID: Facility ID: 676341 If continuation sheet Page 12 of 20 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 03/26/2024 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 0679 Provide activities to meet all resident's needs. 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction both independence and interaction in the community for 2 of 2 residents (Residents #2 and #8) reviewed for activities. Residents Affected - Some 1. The facility failed to ensure activities were consistently provided on the weekends to Residents #2 and #8. 2.The facility failed to provide activities that were important to men in the facility and that was important to Resident #2 . These failures could place residents at risk of becoming apathetic, isolated from others, having a depressed mood, boredom, and loneliness, and a decreased quality of life. The findings include: Record review of Resident #2's quarterly MDS assessment, dated 02/05/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His active diagnoses included hemiplegia and hemiparesis following cerebral infarction (partial paralysis following a stroke), chronic obstructive pulmonary disease (refers to a group of diseases that cause airflow blockage and breathing-related problems), muscle weakness, and chest pain. Resident #2's BIMS was a 15 out of 15, which his cognition was intact. Record review of Resident #2's Care Plan, dated 1/1/24, reflected he used an electric wheelchair for mobility and required one staff assist for toileting, and 2 person assist for transfers. Resident #2's Care Plan reflected that he would join in activities of his choice, but he did not join in on big group activities but had a few people he liked to do activities with. Interventions included, make sure that staff will encourage participation, going to him and inviting him to daily activities and explaining to resident the importance of social interaction and to remind him of activities that he enjoys. Record review of Resident #8's quarterly MDS assessment, dated 03/15/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her active diagnosis included acute kidney failure, anemia (low red blood cell count), heart failure, hypertension (high blood pressure), stroke, anxiety disorder (a group of mental illnesses that cause constant fear and worry), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident #8's BIMS was a 12 out of 15, which indicated she had moderate cognitive impairment. Record review of Resident #8's care plan, dated 12/28/23, reflected she used a wheelchair for mobility and was a supervise by one staff member for toileting and transfer. Resident #8's care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 13 of 20 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 03/26/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected she needed out of room social, spiritual, and stimulus activities and mental stimulation. Interventions included, the activity director will encourage and remind resident of current activities and praise her for coming out of her room for activities and encourage her to continue being active. During an observation of the community posted activity calendar in the facility which was located outside the entrance of the dining room on the wall on 03/24/24 at 10:58 AM reflected the following for 03/24/24: 9:00 AM Social Hour/Coffee, 2:00 PM Movies and 3:00 PM Church. There were no activities specifically for men on the calendar for the month of March. During an interview on 03/24/24 at 11:13 AM, Resident #8 stated there were no weekend activities at the facility at all . An observation of the facility on 03/24/24 at 3:15 PM revealed no church services happening in the cafeteria. During an anonymous interview a resident stated they held church services in the cafeteria, but yesterday they did not have church. The resident stated they did not have church every Sunday. During an interview on 03/25/24 at 11:31 AM, the AD stated she did not work on weekends, only Monday Friday. Weekend nursing staff oversaw activities for residents on the weekends. The AD stated they had church every Sunday. When asked if they had church yesterday, she went to ask other staff and came back and stated they did not have church on Sunday, the 24th. During an interview on 03/26/24 at 8:24 AM, Resident #2 stated there were no weekend activities and he wished there were activities directed towards men, like having a sports channel to be able to watch playoff games together. During an interview on 03/26/24 at 8:27 AM, Resident #8 stated the AD needed help and there needed to be someone on the weekends to follow through on the activities posted on the calendar. Resident #8 stated the only activities on the weekend that happened was church, and that was cancelled a lot. She stated on the calendar it showed there were games happening on Saturdays/Sundays, but those games were just out where residents could use them. Staff did not bring residents to the dining room to play them. She stated if residents wanted to play games, they had to organize it themselves, there were no staff who oversaw them. During an interview on 03/26/24 at 11:37 AM, LVN H stated she worked at the facility since 11/01/2023 and she did not know she was responsible for the weekend activities. She worked several weekends since she started and there were times when a volunteer would come in and do activities with the residents. She stated there was not much going on over the weekends and a possible negative outcome for not having activities for residents would be they could start to get antsy. Many residents stated to her they wanted/needed a schedule and something to do. During an interview on 03/26/24 at 11:40 AM, CNA G stated she worked at the facility for a year and a half and worked the day shift, which included a lot of weekends. She stated they tried to do activities with residents on weekends but sometimes they got busy and could not do what was on the schedule. CNA G stated church was cancelled a lot for various reasons, but they did have it sometimes. She stated families visited on weekends and when residents who did not have family/friends visiting them, and there were not activities for them to do, it made them feel sad. She stated they had board (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 14 of 20 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 03/26/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some games in the dining room, but they did not have anyone leading the games on the weekends, but they were there for them to play if they wanted to. She stated a possible negative outcome for not having weekend or consistent activities would be residents were lost without a schedule, and they could get depressed. During an interview on 03/26/24 at 2:40 PM, the AD stated since she did not work weekends, nurses oversaw activities but there was no specific staff person that was in charge of the weekend activities. If the nurses were too busy, then the CNA's tried to do the activities with the residents . Record review of the facility provided policy titled, Activity Programming, dated 2011, reflected in part: Recreation programs are based on the interest and needs of the residents expressed through activity assessment. Residents expressed needs and interests are included in the development of programs. Activity programs are to be designed based on resident's leisure interests and implemented to meet needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. Programs may take place in mornings, afternoons, and/or evenings that span throughout the entire week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 15 of 20 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 03/26/2024 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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 (Resident #30) of 18 residents reviewed for respiratory care. Residents Affected - Few Facility failed to ensure Resident #30 received oxygen according to physician orders. This failure could place residents at risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: Record review of Resident #30's admission record dated 03/25/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with a more recent admission date of 03/05/22. Resident #30 had diagnoses that included, but were not limited to, heart failure and high blood pressure. Record review of Resident #30's annual MDS completed on 01/05/24 revealed a BIMS of 10 which indicated moderately impaired cognition. Section O of the MDS revealed Resident #30 received oxygen therapy while a resident. Record review of Resident #30's care plan completed on 01/06/24 revealed Resident #30 had a diagnosis of congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue). Oxygen therapy was listed as one on the interventions for this focus area. The care plan had a specific focus area which noted Resident #30 was receiving oxygen therapy. The interventions for this focus area noted Resident #30 was to receive his medications as ordered by a physician and to receive oxygen via nasal cannula at 3.5 lpm. Record review of Resident #30's order summary report dated 03/25/24 revealed an order for continuous oxygen at 3.5 lpm via nasal cannula every shift. This order had a start date of 01/10/23. The order summary report also revealed an order to check Resident #30's oxygen saturation (the percentage of oxygen in the blood) once a shift and as needed. This order had a start date of 10/18/22. During an observation on 03/24/24 at 09:14 AM Resident #30 was in his bed on his back with HOB slightly raised. He was receiving O2 via NC at 5 lpm. During an observation and interview on 03/25/24 at 08:27 AM Resident #30 was lying in his bed on his back with HOB slightly raised. He was receiving O2 via NC at 4.5 lpm. Resident #30 stated he did not change the settings of his oxygen concentrator. During an observation on 03/25/24 at 11:11 AM Resident #30 was lying in his bed flat on his back. He was receiving O2 via NC at 4.5 lpm. During an observation on 03/25/24 at 03:17 PM Resident #30 was lying in his bed with HOB slightly raised receiving O2 via NC at 4.25 lpm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 16 of 20 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 03/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 03/26/24 at 08:16 AM Resident #30 was lying in his bed flat on his back. He was receiving O2 via NC at 4.5 lpm. During an interview on 03/26/24 at 10:24 AM LVN F stated nurses were responsible for setting oxygen concentration levels for residents. She said the nurses knew what level to set the oxygen to by referring to the physician's orders in the EHR. She stated CNAs would not have anything to do with setting oxygen saturation levels. LVN F stated a possible negative outcome of a resident receiving O2 at a higher lpm than ordered by a physician was, It is overload, and it would actually cause them to breath even worse. She stated she worked with Resident #30 regularly. When told his O2 had been at 4.5 and 5 lpm over the last two days she stated, I don't know why it was turned up, but I know he isn't supposed to be that high. During an interview on 03/26/24 at 01:52 PM DON stated the nurses were responsible for setting oxygen concentration levels. She said they knew what level to set by referring to the physician's orders. When asked for a possible negative outcome of a resident receiving O2 at higher levels than ordered she stated, Depending on underlying diagnosis if it is greater than 4 (lpm), they could have a negative reaction . Record review of facility policy titled Respiratory Policies and Procedures and dated 06/01/06 revealed the following: . Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Oxygen is set up, delivered, and monitored by a licensed nurse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 17 of 20 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 03/26/2024 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 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, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 Medication Carts (Medication Cart #2) reviewed for pharmacy services . The facility failed to ensure there were no loose medications in Medication Cart #2. This failure could place residents at risk of not receiving an accurate dose of medication and medications not being maintained at their best therapeutic level . Findings include: Observation on 03/24/24 at 10:21 AM of Medication Cart#2 with RN D revealed 1 loose pill . The loose pill was identified by RN D as being Memantine HCL 5mg tab , which was used to treat mild to moderate Dementia or Alzheimer's Disease . Interview on 03/24/24 at 10:35 AM with RN D revealed a negative outcome of loose medication in medication carts was it could be picked up with hands and it would make it dirty. The RN stated It should be disposed of . Interview on 03/26/24 at 10:19 AM with the DON, when asked what a negative outcome of loose medication in medication carts, the DON stated, I'm not sure how it's related. Residents are not able to access medication carts. We call pharmacy and get medications refilled for that patient . Record review of the facility's policy titled, Storage of Medication, dated 2023, reflected the following: Medications and biologicals are stored safely, securely, and properly following manufactures recommendations or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURE 1. The provider pharmacy dispenses medications in containers that meet legal requirement, including requirement of good manufacturing practices where applicable. Medications are kept and stored in these containers. Only a pharmacist completes transfer of medications from one container to another. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 18 of 20 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 03/26/2024 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 0908 Keep all essential equipment working safely. 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 all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for environment. Residents Affected - Many The facility failed to ensure the water heater in the kitchen was functioning. This failure could place residents at risk of contracting food borne illness due to a lack of readily available hot water in the kitchen for use in sanitizing cooking dishes and surfaces and washing hands. Findings Included: During an observation in the kitchen on 03/25/24 at 10:38 AM 3 large pots were observed with water in them on the stove to boil and use to sanitize the dishes used for cooking breakfast. Kitchen staff were observed lifting the pots of boiling water from the stove and dumping them into the sink. The pots were approximately 2 feet tall and 1.5 feet in diameter. During an interview on 03/26/24 at 08:55 AM DM stated the kitchen had been without hot water going on two weeks. She stated, We got the part yesterday and it fit but it (hot water heater) is still not working. DM stated another part came in about a week ago but it was the wrong part. She said her staff had been boiling water to clean the dishes they used to prepare the meals. During an interview on 03/26/24 at 11:52 AM MS and RM stated they had replaced everything that can be replaced on it (kitchen water heater). They stated they were getting quotes on a new hot water heater just in case it stopped working again. They could not agree on when the hot water heater went out but said they would look back in their logbooks get the information. They stated the plumbers who first looked at the hot water heater ordered the wrong part. MS stated the water heater had been going on and off in the kitchen for 2 weeks. He stated he would go in the kitchen and reset it and it would run for a few hours and then shut off again. During an interview on 03/26/24 at 01:38 PM RM stated the hot water stopped working in the kitchen on 03/14/24. The wrong part came to the facility on [DATE]. The correct part came on 03/25/24 but did not work until they factory reset the water heater on 03/26/24. During an observation and interview on 03/26/24 at 01:50 PM DM stated a possible negative outcome of no hot water in the kitchen for two weeks was, We all have back aches from carrying large pots of boiling water to wash dishes. She demonstrated the size of the pots for boiling water by linking her hands together and making a circle with her arms. During an interview on 03/26/24 at 01:52 PM DON stated regarding the hot water heater in the kitchen, It has been on and off for, I think, 3 weeks. She stated not having hot water readily available in the kitchen could lead to bacterial growth or bad sanitation. During an interview on 03/26/24 at 01:58 PM ADM stated a possible negative outcome of not having a hot water heater in the kitchen for two weeks was the water in dietary services would not be the temperature it needed to be and they would have to boil water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 19 of 20 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 03/26/2024 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 0908 Facility did not provide an Environment Policy. On 03/26/24 RN E stated they could not find an environment policy that pertained to water heaters. 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: 676341 If continuation sheet Page 20 of 20