Inspection·May 21, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some surgical site infection and urinary tract infection. None of Resident #10's active medication/treatment orders mentioned infection or wound. During an observation and interview on 05/19/25 at 03:16 PM Resident #10 was seated in her room. She stated she fell 2 years prior and broke her hip and that was the only time she was hospitalized since she admitted to the facility. She stated she currently did not have any wounds. During an interview on 05/20/25 MDS LVN stated she was responsible for completing MDS assessments. She stated the RAI was the policy she used when completing MDS assessments. MDS LVN stated, Sometimes they (nursing staff) do not take the diagnosis off. She stated that was why Resident #10's MDS indicated a wound infection. She stated, I will modify her MDS right now. MDS LVN stated she did not think residents were negatively affected by an inaccurate MDS. She stated an inaccurate MDS would negatively affect funding for the facility. 2. Record review of Resident #25's admission record dated 05/20/25 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), nicotine dependence, diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and history of pneumonia (lung inflammation caused by a bacterial or viral infection). Record review of facility's list of residents who smoke, provided by ADM on 05/19/25 revealed Resident #25's name. Record review of Resident #25's significant change MDS with an ARD of 03/31/25 and completion date of 04/10/25 revealed the following: Section C Cognitive Patterns: Resident #25 had a BIMS score of 6 which indicated severely impaired cognition. Section J Health Conditions: Resident #25 was listed as not having current use of tobacco. Record review of Resident #25's care plan completed on 04/21/25 revealed a focus area of Resident smokes. Date Initiated: 11/08/23. Record review of Resident #25's Safe Smoking Assessment completed 03/18/25 revealed the following: A. Evaluation1. Does the resident know the location(s) of the designated areas for smoking? 2. Yes 2. Can the resident get to these areas independently? 2. Yes 3. When observed, can the resident independently light smoking materials safely? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 2 of 15 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 05/21/2025 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 1. No Level of Harm - Minimal harm or potential for actual harm 4. Can the resident extinguish smoking materials completely in an appropriate receptacle? 2. Yes Residents Affected - Some 5. Can the resident dispose of ashes or other tobacco-related residue appropriately? 2. Yes During an interview on 05/20/25 at 03:08 PM MDS LVN verified that Resident #25 did smoke and that she (MDS LVN) missed the tobacco use on the significant change of condition MDS completed 03/31/25. She stated she would complete a corrected MDS immediately. 3. Record Review of Resident #34's admission record dated 05/20/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, squamous cell carcinoma of skin of nose (skin cancer). Record review of Resident #34's quarterly MDS with ARD of 04/22/25 and completion date of 04/25/25 revealed the following: Section C Cognitive Patterns: Resident #34 had a BIMS score of 3 which indicated severely impaired cognition. Section O Special Treatments, Procedures, and Programs: Resident #34 was receiving chemotherapy and IV medications while a resident. Record review of Resident #34's care plan completed on 04/07/25 revealed no mention of IV medication. Record review of Resident #34's order summary report dated 05/20/25 revealed no order for IV medication. Record review of Resident #34's MAR for the month of April 2025 revealed no mention of IV medication. During an observation and interview on 05/20/25 at 03:05 PM MDS LVN stated Resident #34 received an IV infusion at a doctor's office. She searched her computer and stated the name of a cancer treatment center. MDS LVN stated the IV infusion was possibly chemotherapy. She searched her computer again and stated, Yes it was for chemo. MDS LVN stated she was not aware that chemotherapy did not count as IV medication on an MDS assessment. She stated she would correct Resident #34's MDS. She stated the correction would definitely affect the facility's funding. During an interview on 05/21/25 at 09:11 AM ADM stated MDS LVN was responsible for completing MDS assessments. He stated, If it (MDS assessment) is inaccurate we might not be doing what we need to do with that resident. During an interview on 05/21/25 at 09:16 AM DON stated she did not think an inaccurate MDS would affect residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 3 of 15 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 05/21/2025 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 An interview was attempted with ADON on 05/21/25 at 10:55 AM by phone. The call was not answered or returned. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: Residents Affected - Some . I: Active Diagnoses in the Last 7 Days . There are two look-back periods for this section: Diagnosis identification (Step 1) is a 60-day look-back period. Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period . 2. Determine whether diagnoses are active: Once a diagnosis is identified it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitory, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. J: Health Conditions . Current Tobacco Use . 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Special Treatments, Procedures, and Programs . IV medications . Do not include IV medications of any kind that were administered during dialysis or chemotherapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 4 of 15 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 05/21/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 (Resident #10 and Resident #57) of 16 residents reviewed for PASRR. 1. The facility failed to refer Resident #10 for PASRR level II assessment, to the state-designated authority, upon receipt of a major depressive disorder recurrent severe diagnosis. 2. The facility failed to refer Resident #57 for PASRR level II assessment, to the state-designated authority, upon receipt of a psychotic disorder with delusions and/or paranoid schizophrenia diagnoses. These failures could place residents at risk of not receiving necessary care and/or services. Findings Included: 1. Record review of Resident #10's admission record dated 05/20/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), brief psychotic disorder (a temporary psychiatric condition characterized by sudden onset of psychotic symptoms, such as delusions and hallucinations, lasting less than one month), and generalized anxiety disorder (inability to control constant worrying). The diagnosis of major depressive disorder recurrent severe had an onset date of 04/05/24. Record review of Resident #10's quarterly MDS completed on 04/07/25 revealed the following: Section C Cognitive Patterns revealed Resident #10 had a BIMS score of 15 which indicated intact cognition. Section I Active Diagnoses revealed Resident #10 had diagnoses of anxiety disorder, depression, and psychotic disorder. Record review of Resident #10's care plan completed on 05/12/25 revealed she had a history of mood problems and depression. She required antidepressant medication. Record review of Resident #10's order summary report dated 05/20/25 revealed the following order: Escitalopram Oxalate Oral Tablet 20 MG . Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES . Record review of Resident #10's most recent PASRR Level 1 Screening revealed an assessment date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 5 of 15 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 05/21/2025 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 0644 10/03/22. The PASRR was negative for mental illness. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #57's admission record dated 05/19/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), delirium due to know physiological condition (a type of acute confusion that can arise from various factors), paranoid schizophrenia (a mental illness characterized by episodes of psychosis including hallucinations, delusions, and disorganized thinking), psychotic disorder with delusions (severe mental illness including distorted beliefs), and major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). The diagnosis of psychotic disorder with delusions had an onset date of 04/04/24. The diagnosis of paranoid schizophrenia had an onset date of 04/22/25. Residents Affected - Few Record review of Resident #57's quarterly MDS completed on 04/21/25 revealed the following: Section C Cognitive Patterns revealed Resident #57 had a BIMS score of 9 which indicated moderately impaired cognition. Section I Active Diagnoses revealed Resident #57 had diagnoses of depression and psychotic disorder. Record review of Resident #57's care plan completed 03/24/25 revealed Resident #57 has mood problem related to vascular dementia and paranoid schizophrenia. Resident #57 required antidepressant and antipsychotic medication. Record review of Resident #57's order summary report dated 05/19/25 revealed the following orders: Donepezil HCI Oral Tablet 5 MG . Give 2 tablet by mouth one time a day related to . PSYCHOTIC DISORDER . risperiDONE Oral Tablet 1 MG . Give 2 tablet by mouth one time a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION . Sertraline HCI Oral Tablet 100 MG . Give 1 tablet by mouth one time a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION . Record review of Resident #57's EHR under the miscellaneous tab revealed Resident #57's most recent PASRR Level 1 Screening had an assessment date of 03/19/25. The PASRR was positive for a primary diagnosis of dementia and negative for mental illness. During an interview on 05/20/25 at 10:48 AM MDS LVN stated she was responsible for completing PASRR screening. She stated if a resident received a new mental illness diagnosis after having a negative PASRR I they should have received a new PASRR I to determine if they were eligible for services based on the new diagnosis. MDS LVN stated she should have but did not run new PASRR screenings on Resident #10 and Resident #57. MDS LVN stated she did not think either resident was negatively affected by her failure to run new PASRR screenings due to both residents having a primary diagnosis of dementia (this would cause them to be ineligible for PASRR services). She stated, I don't think it would impact the residents per se because they are long term care, and their care is not going to change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 6 of 15 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 05/21/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/20/25 at 10:59 AM ADM stated MDS LVN was responsible for completing PASRR screenings. He stated not doing a new PASRR screening following a new qualifying mental health diagnosis could negatively impact a resident because they might not get services they need. During an interview on 05/21/25 at 09:16 AM DON stated if a resident with a new mental illness did not receive a new PASRR screening they won't receive needed services if they are PASRR positive. Record review of facility policy titled PASRR Level 1 Screen Policy and Procedure and dated 3-6-2019 revealed no mention of re-screening residents following newly qualifying diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 7 of 15 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 05/21/2025 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 (Resident #27) of 3 residents reviewed for respiratory care. Residents Affected - Few The facility failed to store Resident #27's nasal cannula properly. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings include: Record review of Resident #27's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 08/12/22 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease(a group of lung diseases that block airflow and make it difficult to breath), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), bipolar disease (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), and panic disorder (a disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptom that may include chest pian, heart palpitations, and shortness of breath). Record review of Resident #27's clinical record revealed her last MDS was a quarterly completed 3-28-2025 listing her with a BIMS score of 15 indicating she was cognitively intact, and she had a functionality of requiring set-up/clean-up assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #31 was marked as having oxygen While a Resident. Record review of Resident #27's Order Summary Report with Active Orders as of 05/20/2025 revealed the following orders: - May use oxygen @1-5 l/m via nasal canula two times a day. Active 04/17/2025. - Change nasal canula as needed for maintenance. Active 12/22/2023 Record review of Resident #27's clinical record revealed a care plan with the admission date of 12/22/23, which revealed the following: Focus: The resident has Oxygen Therapy - Ineffective gas exchange. Date Initiated: 10/17/2022. -there were no interventions for respiratory equipment care to include nasal cannula storage. During an observation on 05/19/25 at 10:10 AM Resident #27 was observed in her room sitting in a recliner with no bed present. Resident #27 had her nasal cannula on the floor next to the O2 concentrator that was next to her recliner. Resident #27 reported that she used her oxygen only at night and that she did not need it during the day. There was no date of when the oxygen tubing or nasal cannula had been changed. The nasal prong area of the nasal cannula appeared brownish and discolored from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 8 of 15 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 05/21/2025 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 use. There was no storage bag provided for the nasal cannula. Level of Harm - Minimal harm or potential for actual harm During an observation on 05/19/25 at 12:19 PM revealed Resident #27 was not in her room, but her nasal cannula was still on the floor in the same position between her recliner and her oxygen concentrator. Residents Affected - Few During an observation on 05/19/25 at 02:22 PM revealed Resident #27 was not in her room, but her nasal cannula was still on the floor in a slightly different position between her recliner and her oxygen concentrator. During an observation on 05/19/25 at 03:19 PM revealed Resident #27 was in her room sitting in her wheelchair listening to her headphone. Resident #27's nasal cannula was still on the floor between her recliner and her oxygen concentrator in the same position as observed on 05/19/25 at 02:22 PM. During an observation on 05/20/25 at 09:09 AM revealed Resident #27 was in her recliner with her oxygen on. Her nasal cannula was observed to have the same brownish discoloration. Resident #27 was sleeping and did not wake to introduction. During an observation on 05/20/25 at 10:04 AM revealed Resident #27 was not in her room. This observation revealed that the nasal cannula had been replaced and was stored in a bag hanging from the back of the oxygen concentrator. During an interview on 05/21/25 at 07:48 AM LVN B (nurse for the 400 Hall this shift who reported this was her first day to work this week) reported that staff were to make rounds of the resident's room every 2 hours and that they are to check on the resident's oxygen concentrator to ensure that the equipment such as the nasal cannula and tubing are stored correctly. LVN B reported that if a nasal cannula was found on the floor, then it should be replaced, and a bag should be provided so the new nasal cannula could be stored properly off the floor. LVN B reported that if a nasal cannula was left on the floor, then it could become dirty, full of water from the hydration chamber when the machine is on, and it could be an infection problem. During an observation and interview on 05/21/25 at 08:07 AM revealed Resident #27 was in her room sitting in her recliner wearing her headphones resting peacefully. Resident #27 had her oxygen stored correctly in the bag provided behind her O2 concentrator. Resident #27 was asked about her nasal cannula being on the floor on 5/19/25 and Resident #27 reported that she did not really pay attention to that, that she just reached beside her recliner until she feels the tubing and then puts it on. Resident #27 reported that she has not really thought about it being on the floor and didn't really have an opinion either way. During an interview on 05/21/25 at 08:46 AM CNA A (CNA for the 400 Hall this shift) who reported that she was not working on 5/19/25. CNA A reported that staff were to make rounds every two hours, and that they were supposed to check the resident oxygen concentrators, tubing, and nasal cannulas. CNA A reported that the staff should make sure that they have water for the concentrator and that the nasal cannulas were in good shape. CNA A reported that if a nasal cannula was found on the floor, then they throw it away and get a new one because that one could be cross contaminated with whatever was on the floor or someone could have stepped on it, During an interview on 05/21/25 at 11:15 AM the DON reported that staff were to make rounds every 2 hours, they were to check the oxygen concentrators when in the room to make sure they were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 9 of 15 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 05/21/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete functioning and have water, and if the nasal cannula was on the floor, then they were to throw the nasal cannula away and replace it. If the nasal cannula was not replaced, then that could be a violation of infection control. During an interview on 05/21/25 at 12:30 PM the CN reported that the facility did not have a policy for care of respiratory equipment. Event ID: Facility ID: 676341 If continuation sheet Page 10 of 15 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 05/21/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 1 locked unit. The facility failed to have sufficient staff on the locked unit. This failure could place residents at risk of harm due to neglect. Findings Included: During an observation on 05/19/25 beginning at 11:50 AM 15 residents were noted to be residing on the locked unit. 6 residents were in the common area with one staff member. Two other staff members were observed on the locked unit. During an interview on 05/19/25 at 06:47 PM Resident #57's family member stated regarding the locked unit where Resident #57 resided, I don't think they have enough people on that hall. I know they are in compliance with the state, but the state does not spend time on that hall like I do. Recently they have had 2-3 staff on the hall but there have been times there was only one person on the hall. During an interview on 05/20/25 at 07:17 PM Resident #28's family member stated of the locked unit where Resident #28 resided, I think there is just one (staff) person back there most of the time. During a confidential interview Staff Member K revealed they often worked alone on the locked unit. Staff Member K stated they worked on the locked unit alone all the time. Just not this week because you're (state surveyors) here. Staff Member K stated they transferred 2-person transfer residents on the locked unit alone. They stated, A couple of them (residents on the locked unit) are 2-person assists but it is not too much for my body to do it because they are able to stand. I think it is just a fall risk. During a confidential interview Staff Member L stated they often worked alone on the locked unit. Staff Member L stated they transferred residents who needed 2-person assist without help when they were working the locked unit alone. During a confidential interview Staff Member M stated they often worked alone on the locked unit day shift (6 am-6 pm). Staff Member M stated they had been keeping notes on the days they worked alone on the locked unit because I didn't want you guys (state surveyors) to come and me to lose my license. Staff Member M provided a list of 11 days (one day in February 2025, 6 days in March 2025, 4 days in April 2025) in the last two and a half months when they worked the locked unit alone. Staff Member M stated on one of the days they were alone they sent a text to DON asking for help and no help was received. Staff Member M stated working the locked unit alone can be too much. They stated they used to transfer 2-person assist residents alone but do not do so anymore. Staff Member M stated, Last month or the month before the hall (locked unit) was completely full and it was me by myself and a lot of them (residents on the locked unit) are high fall risk and it is hard to manage them when I have to help another resident with something. When there are just 8 (residents on the locked hall) or so it is a lot easier to deal with. They stated when they needed assistance on the locked unit, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 11 of 15 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 05/21/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm they had to text DON or another CNA in the facility. They stated CNAs on some shifts were more willing to assist than CNAs on other shifts. During an interview on 05/20/25 at 03:23 PM ADM stated the facility did not have a staffing policy for the locked unit or for the facility as a whole. He stated, We are not a certified unit back there (locked unit). Residents Affected - Some During an interview on 05/21/25 at 08:32 AM SNA C stated transferring a 2-person assist resident alone could result in hurting yourself or hurting the resident. She stated, There could be a fall. During an interview on 05/21/25 at 08:33 AM LVN B stated transferring a 2-person assist resident alone could result in injury to the resident. She stated, That is negligence, they could fall. During an interview on 05/21/25 at 09:11 AM ADM stated it was not safe to transfer a 2-person assist resident alone. He stated, There is a reason for (2-person assist): resident safety. During an interview on 05/21/25 at 09:16 AM DON stated she was responsible for staff schedules on the locked unit. She stated one CNA for 15 residents on the locked unit was sufficient staff, Depending on what is going on back there. We don't have a staffing ratio for the (locked) unit. There are always nurses available and assigned to that hallway. The nurse is assigned to that hallway and one other hallway. DON stated she did not think having one CNA on the locked unit would negatively impact residents. She stated, Their (CNAs') communication is really good. As long as they communicate with us that they need more assistance. DON stated transferring a 2-person assist resident alone might not negatively affect the resident. She stated, Depending on the resident. They (residents) go from 2 (person assist), to 1 (person assist), to ambulatory back there (locked unit) a lot. Record review of facility census on 05/19/25 revealed the locked unit with 15 residents was approximately 23% of the total census of 63. Record review of the last 6 months (from 11/20/24 to 05/20/25) facility reported incidents revealed 9 of the 17 (approximately 53%) facility reported incidents occurred on the locked unit. Eight of the incidents had allegations of resident abuse and neglect due to residents hitting/pulling one another and pulling each other's pants down. The other incident had an allegation of injury of unknown origin. None of the incidents indicated injury of a resident due to inappropriate transfer or mentioned inappropriate transfer. Record review of the 4 months of staffing schedule provided by DON for the locked unit from 01/20/25 to 05/20/25 revealed the month of March was missing as was the schedule for 04/01/25. Of the remaining 89 days, 80 days had portions of the day when only one staff member was scheduled to work on the locked unit. 33 of those days the staff person working alone on the locked unit was not certified or licensed but was a hospitality aide or an uncertified nurse aide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 12 of 15 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 05/21/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 lunch meals reviewed for menus and nutritional adequacy on 5/19/25 in that: Residents Affected - Some A. Dietary staff did not serve cherry fried pies to 17 residents on a mechanical soft diet on 5/19/25 (Residents # 2,11,12,15, 19, 22, 26, 32, 38, 40, 43, 45,47, 52, 56, 59, and 64). B. Dietary staff did not serve pureed bread, pureed fried cherry pie, pureed potato salad or pureed bread butter pickles and onion during the noon meal on 5/19/25 for 2 residents reviewed for pureed diets (Resident #s 23 and 53). These failures could place residents who eat mechanical foods and residents who eat pureed foods at risk of not having their nutritional needs met. Findings included: Record Review for the Monday lunch meal for 5/19/25/ revealed the planned menu for the noon meal was BBQ Pork on a bun, baked beans, potato salad, bread and butter pickles and onion, cherry fried pie and iced tea. Record review of the facility diet spreadsheet for the noon meal on 5/19/25 indicated residents on mechanical soft and pureed diets were to receive all foods listed on the menu. During an interview on 5/19/25 at 10:30 AM, the DM stated there were 2 residents in the facility with pureed diets. In an observation on 5/19/25 from 11:55 am to 1:00 pm of the facility lunch meal it was observed that residents with a mechanical soft diet listed on the individual meal ticket did not receive a fried cherry pie. The residents were served applesauce instead. Residents with a pureed diet did not get the fried cherry pie. They were served applesauce. Observations of the pureed meals revealed residents with pureed diets were served BBQ meat and beans with a serving of applesauce. Residents on a pureed diet also did not receive potato salad, bread and butter pickles and onion. In an observation and interview on 5/19/25 at 12:30 pm Resident # 64 's meal tray did not have a fried cherry pie. Resident #64 tray had applesauce instead of the cherry fried pie. Resident # 64 stated she did not like applesauce. She stated she would rather have the fried pie, but no one asked her what she wanted. During an observation and an interview on 5/19/25 at 12:35 pm, Resident #134's meal tray did not have a fried cherry pie. She had apple sauce on her tray. Her family member stated she loves cherry pie and did not get one. He stated he did not know why she did not get a cherry pie for lunch. He stated the resident did not like applesauce but would eat it if presented with it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 13 of 15 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 05/21/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation on 5/19/25 at 12:37 pm of the pureed meal served to residents in the dining room at lunch, there was no bread, potato salad, bread, pickles and onion or fried cherry pie. Residents on a pureed diet were provided a bowl with a brown substance that smelled like BBQ and a bowl with a brown food that smelled like beans and a serving of applesauce. In an observation on 5/19/25 at 12:39 pm of Resident # 53's pureed meal there was no bread, potato salad, bread, pickles and onion or fried cherry pie. Resident was provided a bowl with a brown substance that smelled like BBQ and a bowl of brown food that smelled like beans and a serving of applesauce. In an interview on 5/19/25 at 12:10 pm the Director of Rehabilitation (OTAG) stated the residents on mechanical soft and pureed diets could have all the menu items listed on the menu. She stated at one point for one person the fried pie was too hard to eat so the kitchen was told not to give him the fried cherry pie but that resident was no longer in the facility. She stated the comment was not meant to be used for all mechanical and pureed diets across the board for the rest of time. She stated the residents need all the calories they can get and need to be offered all foods. She stated she saw the residents got applesauce a lot. In an interview on 5/19/25 at 12:40 pm, [NAME] J stated she had pureed all the food listed for the residents on pureed diets. She stated the residents on pureed and mechanical soft diets did not get the fried cherry pie as the rehab department told them not to give the residents the fried cherry pies. She stated the pie would not puree properly. She stated they were getting applesauce. In an interview on 5/20/25 at 11:50 am, the DM stated she was not aware the residents on pureed diets did not get all the menu items listed. She stated the bread was not pureed but should have been. She stated she did not know why it was not pureed. She stated the residents on a pureed diet did not get the fried pies and were given applesauce instead. She stated the ST told her residents on a mechanical soft and pureed diets could not have the fried pies, so those residents were given applesauce instead. She stated the expected the cook to puree all foods listed. She stated applesauce was not a good nutritional alternative to fried cherry pie. In a confidential interview on 5/21/25 at 8:50 am, one staff member stated every day the staff had to go to the kitchen staff and ask for a roll or other foods the residents did not get. Both residents with mechanical soft and pureed diets did not get what was listed on the menu for most days. The staff member stated the consequences of not getting the correct menu items would be weight loss. In an interview on 5/21/25 at 8:55 am, the ST stated normally she was in the dining room during meals so she could monitor the residents' meals. She stated it had been a battle she had been having for over a year trying to make sure the residents got the foods listed on the menu. She stated the kitchen could have pureed the pies for the residents with pureed diets, but they did not. She stated it was just laziness on the kitchens part. She stated there was no reason the residents with mechanical soft and pureed diets could not have everything on the menu. She stated all residents could have the pureed pies and bread and the mechanical soft diets could have the pies. She stated the consequences of not getting all the foods listed on the menu could result in weight loss. In an interview on 5/21/25 at 9:20 am the DM stated if relish was served, residents on a pureed diet would have been served tomato juice. She stated residents on a pureed diet were not given tomato juice in place of the pickles and onion for the 5/19/25 noon meal. She further stated she was not aware the residents on a pureed diet did not get bread or potato salad. She stated she was a new DM and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 14 of 15 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 05/21/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the previous DM had not trained the cooks for the job. She stated the kitchen had been short staffed. She stated she tried to watch what was going on but the kitchen had been short staffed and she had not been able to watch and train staff as she needed to. She stated [NAME] J was not really on top of things when pureeing foods. The DM stated the corporate person for the dietary department spent 2 days with her when she started. She stated the consequences of not serving all menu items to residents were residents would have weight loss and loss of satisfaction of food. In an interview on 5/21/25 at 1:15 pm, the Regional DON stated she expected all residents to be given all menu items as listed on the menu. She stated the meal tickets for each resident should match the menu. She stated the nurses were supposed to check the trays to ensure accuracy as they go out to the resident. She stated meal monitoring was done by different department heads. She stated the consequences of not getting all the menu items listed were weight loss. Record Review of the facility policy titled, Nutritional assessment and Patient Care Plan Documentation dated 2012 revealed: The DM perform regular meal rounds to observe residents' overall meal acceptance, texture tolerance, positioning and feeding. Record Review of the facility policy titled, Consistency Modification dated 2012 revealed: Guidelines for pureed diets: Foods are blended following the regular diet for the day. Record Review of the facility policy titled, Menu Approval dated 2012 revealed: Policy: Menus will be planned to meet the nutritional needs and preferences of the residents and are in accordance with the recommended daily allowances of the food and Nutritional Board of the National Research Council, National Academy of Sciences. Every attempt will be made to honor resident food preferences. The menus will reflect the religious culture as well as the resident population as well as input received from residents and resident group. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676341 If continuation sheet Page 15 of 15